Sex Worker-Led HIV Programming Global report

Transcription

Good Practice in
Sex Worker-Led
HIV Programming
Global Report
Contents
Good practice in sex worker-led
HIV programming: Global Report . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Barriers to health. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2
Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Summary of best practices. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5
Summary of recommendations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
Case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
AFRICA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9
ASIA and THE PACIFIC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
23
EUROPE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33
LATIN AMERICA. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
45
NORTH AMERICA and THE CARIBBEAN . . . . . . . . . . . . . . . . . . . . . . . . . . .
55
Best practices by sex worker-led organisations . . . . . . . . . . . . . . 67
Recommendations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
Conclusion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 80
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81
Good Practice in Sex Worker-Led HIV Programming: Global Report
GLOBAL NETWORK OF SEX WORK PROJECTS
Good practice in sex worker
-led HIV programming:
Global Report
Introduction
To date less than 1% of global funding for HIV prevention has been spent on
HIV and sex work (UNAIDS, 2009), yet concerns about HIV and other sexually
transmitted infections (STIs) are among those invoked to justify laws and
policies which contribute to the multiple human rights violations suffered by
sex workers worldwide. Paradoxically, these violations serve to put sex workers’
lives at risk, including with regard to their sexual health. The barriers to health
faced by sex workers are manifold, ranging from police confiscation of their
condoms for use as evidence against them, to hate crimes against sex workers
encouraged by widespread stigma which paints them as ‘vectors of disease’,
and health care services which may be overly expensive, disrespectful of
confidentiality, inaccessible to undocumented migrants, or conditional upon a
commitment to leave the sex industry.
Around the world, sex worker-led organisations are succeeding, some
against great odds, in delivering HIV programming which takes into account
the complexities of sex work and recognises the essential need for direct
consultation with, and the active involvement of, the intended beneficiaries
of services. Their pragmatic approach is typically characterised by a nonjudgemental attitude, an intersectional analysis of oppression, and a firm
commitment to the demand “nothing about us without us”. In taking this
approach, they have gained the trust of the sex workers they serve and have
seen genuine improvements in their holistic health, including decreased rates
of HIV and other STIs and access to appropriate treatment for HIV-positive sex
workers. Some of the organisations profiled in this report have made significant
headway in making local health care and social service providers, along with
law enforcement officers, aware of the sometimes complex issues affecting
sex workers, resulting in more effective and welcoming services. Despite these
successes, the organisations themselves often operate on a shoestring budget
and in an unfavourable political climate which sees widespread stigma and
hostility towards sex workers and other marginalised groups.
1
Funding provided by the Robert Carr civil society Networks Fund enabled the
Global Network of Sex Work Projects (NSWP) to implement a global project
identifying and documenting best practices by sex workers in providing services
related to sex work and HIV. This resulting report presents examples of services
around the world which take a rights-based approach in delivering effective
and respectful HIV programming to sex workers. Although their demographics
and circumstances are diverse, with variations in legal prohibitions against sex
work-related activities, rates of HIV and target groups, the recurrence of certain
themes is striking. Beyond mere provision of safe sex supplies and safe sex
education – crucial as these things are – it is clear that stigma plays a prominent
role in disempowering sex workers and putting them at greater risk of exposure
to HIV.
Acknowledgements
NSWP would like to thank Robert Carr civil society Networks Fund and Bridging
the Gaps Programme for financial support in producing this report.
The following people are also thanked for their contributions to the
development of the project:
Global: Gillian Galbraith, Mitch Cosgrove, Nine, Neil McCulloch; Africa:
Grace Kamau Mukuhi, Daughtie Ogutu, John Mathenge, Phelister Abdallah,
Penninah Mwangi; Asia and the Pacific: Khartini Slamah, Nukshinaro
Ao, Rena Janamnnuaysook, Chamrong Phaengnongyang, David Trynot;
Europe: Agata Dziuban, Pye Jakobsson, Stasa Plecas, P.G. Macioti, Luca Stevenson,
Kristina Mahnicheva, Irina Maslova, Carina Edlund, Borche Bozhinov,
Shahnaz Islamova, Dinara Bakirova; Latin America: Cynthia Navarrete,
Cida Viera, Karina Bravo, Alejandra Gil, Angela Villon; North America and the
Caribbean: Sandra KH Chu, Elya Durisin, Penelope Saunders, Cracey Fernandes,
Miriam Edwards, Marcus Day.
Barriers to health
Discrimination
Many service providers appear to be either oblivious to, or unwilling to
address, the myriad oppressions experienced by sex workers. As well as
facing discrimination based on their engagement in sex work, they may also
experience sexism, misogyny, transphobia, homophobia, racism, xenophobia,
ableism, classism, discrimination based on HIV status (real or perceived), and/or
other forms of prejudice.
Fear of discriminatory treatment – often based on first-hand experience of it –
impacts sex workers’ access to services, including their willingness to report
crimes to the police and seek health care. For migrant sex workers, this may be
compounded by linguistic constraints and/or lack of documentation. A great
deal of services express judgemental and uninformed views on sex work – as
well as homophobic and transphobic attitudes towards lesbian, gay, bisexual
and transgender (LGBT) people, particularly in countries where LGBT people are
criminalised and demonised by the media and religious institutions – which
may turn sex workers away, intentionally or not.
Access to some services is granted only on the condition that sex workers exit
the sex industry, or commit to doing so. This approach rejects their own agency
and is not a pragmatic response to their immediate circumstances. Services for
sex workers should not have conditions attached.
2
Criminalisation
It is abundantly clear that criminalisation of any aspect of the sex industry
impacts negatively upon sex workers’ health. Regardless of whether the
criminalisation is of sex work itself or of associated activities, and regardless of
whether sex workers, clients or third parties are the targets of criminalisation,
these regulations serve to drive sex work further underground, disrupting
sex worker networks and depriving sex workers of control over their working
conditions. An absence of safe and supportive working environments severely
disempowers them, undermining their ability to consistently engage in safe
sexual behaviour. Those who work alone to avoid attention from police and
members of the public are more vulnerable to violence and exploitation, and it
may be harder for support services to make contact with them, which deprives
them of access to crucial information which could enhance their safety,
including information on violent individuals posing as clients. Laws against
sex work or associated consensual activities enhance the stigma which can
impact all areas of sex workers’ lives and prevent them from enjoying full rights
as citizens. It should be noted that the ideology behind the laws makes little
difference in practice: whether engagement in sex work is viewed as a question
of immorality or of victimhood, the results are much the same.
Laws criminalising LGBT people further compound the vulnerability and
isolation of male and transgender sex workers, who experience additional abuse
and discrimination based on their gender expression and (perceived) sexual
orientation. Furthermore, laws criminalising HIV non-disclosure, exposure
and transmission discourage sex workers from getting tested for HIV for fear of
arrest and imprisonment, or from seeking appropriate health care should they
test positive. Migrant sex workers may additionally fear being reported to the
authorities in countries which deport HIV-positive migrants.
Police abuse
It is by no means uncommon for sex workers around the world to experience
human rights violations at the hands of police. These include extortion; bribery;
verbal abuse and harassment; beatings and sexual violence; illegal detention;
torture; and even, as in the Russian Federation, murder. Additional violations
include public screening of footage from raids, putting sex workers at risk of
being recognised, as in Kyrgyzstan; failure to act on sex workers’ reports of
violence (sometimes arresting those reporting it instead); forced HIV testing;
and use of condoms as evidence of sex work and/or trafficking. Arrests of sex
workers may also cause them to miss medication, leading to ineffective and
abandoned treatment. Police crackdowns drive sex workers away from support
services, preventing outreach workers from distributing safe sex supplies and
potentially life-saving information. Those seeking to influence the laws of
foreign countries on sex work and trafficking should recognise that sex workers
often experience persecution at the hands of the police and that granting police
further powers may exacerbate this.
Shortcomings in health care services
Problems experienced by sex workers in their interactions with health
care staff include violations of confidentiality; beliefs that sex workers are
unworthy of treatment; and, as reported in Macedonia, refusals to treat male
and transgender sex workers. A lack of follow-up to complaints compounds
these deterrents. Many sex workers may avoid revealing their occupation to
health care staff for fear of being patronised, judged or discriminated against.
Further barriers to accessing health care include inflexible schedules; high
fees; shortages of medication; long waits for HIV and STI testing; restrictions
on access to prophylactics; bans, as in the Russian Federation, on substitution
treatment for people who use drugs; and restrictive regulations on migration
which impact migrants’ access to health services. An absence of free or
affordable HIV treatment is a particular deterrent to sex workers learning their
HIV status, especially migrant sex workers who may face higher fees than
nationals or may fear being reported to the authorities.
3
Inadequacy of programming for sex workers
Programmes specifically aimed at sex workers may nonetheless target only
a small percentage of the sex worker population, whether due to a lack of
political will or to insufficient research and awareness of sex workers’ actual
needs. Assumptions that sex workers are a homogeneous group serve to
alienate those who do not fit prevailing stereotypes, and services provided
may be irrelevant to their circumstances.
Shortages of funding for sex worker-led
and -centred programming
Sex worker-led organisations have the expertise needed to respond adequately
to sex workers’ actual needs and to deliver effective services that empower
them to stay safe. However, around the world, whether in high-, low- or
middle-income countries, these organisations suffer from a lack of funding,
which is in some places compounded by authorities who deny them official
registration due to a refusal to recognise sex work as an occupation. Relatively
few donors have demonstrated an intersectional awareness of sex work issues
and a commitment to responding to them. More commonly, funders lean
towards ‘exit’ programmes, which, though they may meet the needs of some
sex workers, place lesser emphasis on assisting sex workers to stay safe while
engaging in sex work, and do not take a workers’ rights perspective. Services
which see sex work as harmful, immoral or violence against women alienate
sex workers and discourage them from attending, especially those which also
campaign for criminalisation (nowadays, most commonly the criminalisation
of sex workers’ clients) and for greater police powers against the sex industry.
Sex workers feel they are not heard and not represented by such organisations
and see little work being done to meet their needs in a repressive political
climate.
Methodology
Consultants were contracted to carry out research in each of the five regions:
Africa; Asia and the Pacific; Europe (also encompassing Central Asia); Latin
America; and Canada, the USA and the Caribbean. After consultation with
the relevant regional advisory group, four sex worker-led HIV programmes
were selected in each region, in order to present examples of best practice.
Organisations were defined as sex worker-led if 50% or more of the decisionmaking body was comprised of current or former sex workers; if 50% or more
of the spokespeople were current or former sex workers; and if 33% or more of
any paid staff were current or former sex workers.
In most circumstances, a survey was also distributed to collect information
on issues affecting sex workers in the region, and the chosen programmes
visited for further discussions and accompaniment on fieldwork. Deciding
factors in their selection included their focus on bridging the gaps; a holistic,
human rights and community empowerment approach to HIV programming;
reflection of the diversity of socio-environmental settings; and specific
challenges faced by sex workers in terms of human rights violations and
access to health care.
The following pages summarise the twenty case studies, providing snapshots
of effective health interventions led by sex workers as well as further insight
into the obstacles they face not just in accessing HIV prevention and health
services but in enjoying full rights as citizens.
4
Summary of best practices
Discussed in greater depth following the case studies, the points below
comprise best practices by sex worker-led organisations:
◗◗ Offer services that meet sex workers’ needs
Make sure that drop-in centres, outreach activities and overall service
provision demonstrate awareness of sex workers’ circumstances, with
particular attention given to location, opening hours, confidentiality and
preferred methods of contact.
◗◗ Ensure that funding sources have sex workers’ best interests at heart
Prioritise sex workers’ needs over those of international donors; explore
alternative methods of funding, such as the union model.
◗◗ Run services effectively and smoothly
Map sex workers for outreach purposes, regularly update information and
keep secure records.
◗◗ Ensure inclusion of all sex workers
Aim to include migrant and HIV-positive sex workers, as well as those who
sell sexual services but do not identify as sex workers.
◗◗ Aim for programming led by sex workers
Train sex workers as paralegals, HIV testing and counselling (HTC) staff and
peer educators.
◗◗ Aim for community empowerment
Empower and mobilise sex workers to demand their rights and
become leaders.
◗◗ Engage with sex industry gatekeepers
Educate brothel managers and venue owners on HIV and sex workers’ rights.
◗◗ Engage with the government
Consistently take a human rights-based approach in consultations with
government agencies, ensuring that the issues of sex workers and other
marginalised communities remain on the agenda.
◗◗ Engage with law enforcement agencies
Develop a working relationship with law enforcement agencies where
possible; offer training on sex workers’ issues and take a human rights-based
approach in lobbying and advocacy activities.
◗◗ Engage with health professionals
Educate health professionals in order to reduce discrimination against
sex workers.
◗◗ Engage with the media
Network with reliable journalists and target the media to change the general
public’s perception of sex work.
◗◗ Demand justice
Challenge unjust laws by reaching out to those impacted by them and
developing legal proposals.
◗◗ Forge alliances
Network with human rights organisations, civil society organisations, health
professionals, feminists, and other key affected populations, as well as other
local, regional and global sex worker-led organisations and networks.
5
Summary of recommendations
The following points, discussed in greater depth later in this report,
summarise the recommendations for sex worker-led organisations, other
service providers, donors, governments and policy makers:
◗◗ Prioritise sex worker-led interventions
Recognise that sex workers are best placed to determine what sex workers
need, rather than basing their assessments on stereotypes and poor
information.
◗◗ Base services on evidence, responding to actual needs
Ensure that data on sex work is up to date and obtained through ethical
research, and that anti-trafficking initiatives have involved consultation
with sex workers.
◗◗ Prioritise sex workers’ needs over those of funders
Adopt a rights-based approach to funding and recognise that sex workers’
needs and rights go beyond HIV and sexual health services.
◗◗ Enhance sex worker-led organisations’ access to funding
Ensure long-term funding for sex worker-led organisations and expand
eligibility to all such organisations whether they are in low-, middle- or
high-income countries, recognising the structural barriers that they
frequently face.
◗◗ Promote decriminalisation and law reform
Aim for the repeal of laws which contribute to sex workers’ vulnerability
to HIV, including the criminalisation of sex work and related activities.
◗◗ Involve sex workers in law and policy reform and development
Recognise sex workers’ expertise and demonstrate a willingness to listen.
◗◗ Afford protection under the law
Introduce explicit legal protection against discrimination based on
occupation (including sex work), health status, sexual orientation and
gender identity.
◗◗ Enforce zero tolerance of police abuses
Demonstrate accountability for police harassment of, and violence
against, sex workers, and seek to change sex workers’ perception of law
enforcement from persecutors to protectors.
◗◗ Grant access to labour rights
Recognise sex work as work and ensure safe working conditions through
employment standards and occupational health and safety legislation,
as well as access to state benefits.
◗◗ Enhance awareness about rights
Ensure that sex workers are aware of their rights in terms of legality and
empower them to make complaints if treated unfairly by law enforcement
or social service providers.
◗◗ Document human rights violations
Combat stigma, discrimination and judgemental approaches from
service providers.
◗◗ Eliminate coercive testing
Recognise that sex workers have the right to decide where, when and
whether they get tested, and ensure that testing services are respectful
and confidential.
6
◗◗ Address structural inequalities
Work to reduce poverty, create and expand employment opportunities,
and ensure education for all.
◗◗ Ensure inclusion of transgender sex workers
Include sex workers of all genders, recognise transgender women as
women, and ensure that transgender male and gender non-conforming
sex workers in particular are not alienated by services.
◗◗ Empower the sex worker community
Create solidarity among sex workers and engage with them continuously
to raise awareness of sex workers’ rights.
◗◗ Form trade unions
Enable sex workers to collectively demand labour and other rights,
without relying on funding from external sources.
◗◗ Avoid hierarchies
Grant an equal share of power to members of sex worker collectives.
◗◗ Harness the internet in service provision
Recognise that sex workers increasingly use the internet to make contact
with clients and one another, and offer support online.
◗◗ Make use of social media in advocacy work
Use social media to educate the public on issues faced by sex workers and
to gain public support for sex workers’ rights.
◗◗ Strengthen local, national, regional and global sex worker networks
Engage with other sex worker collectives, organisations and networks
to draw connections between the experiences of sex workers locally
and beyond.
◗◗ Build coalitions and alliances across sectors
Engage with health care professionals, lawyers, human rights activists,
policy makers, local and national governments, non-governmental
organisations, representatives of the private sector or media, and other
stakeholders to promote sex workers’ rights.
◗◗ Involve sex workers in service development
Ensure meaningful consultation with sex workers in designing, planning,
implementing and evaluating health, social and legal services for them.
◗◗ Ensure access to social and legal services
Support and ensure accessible, non-discriminatory, user-friendly and
affordable social and legal services.
◗◗ End discrimination in access to health services
Reject coercive programmes, preserve confidentiality, and ensure that
services are accessible to all sex workers, regardless of their gender,
sexual orientation, work environment, socio-economic status or drug use.
◗◗ Ensure access to HIV services for all migrants
Enable migrants to access quality treatment without fear of disclosure
of their HIV or immigration status to the authorities, and end the
deportation of HIV-positive migrants.
◗◗ Ensure that health services are appropriate and accessible
In partnership with sex workers, train health care providers on sex
workers’ rights and needs in order to eradicate stigma and discrimination
within services.
7
◗◗ Ensure that services are inclusive of all sex workers
Recognise the diversity within the sex worker community and aim to
address the needs of all, especially the most vulnerable and marginalised.
◗◗ Promote and provide safe sex and drug harm reduction supplies
Supply sex worker-led organisations with safe sex and drug harm reduction
supplies for distribution, along with promotion of their correct and
consistent use.
◗◗ Promote and enable access to asymptomatic STI screening
Encourage sex workers to get tested after exposure to risks, rather than
waiting until symptoms materialise.
◗◗ Promote voluntary HIV testing
Ensure that sex workers in all areas have access to free and confidential
HIV testing, linked to HIV treatment, care and support services, provided
in accordance with human rights standards.
◗◗ Address sex workers’ vulnerability to HIV in all its complexity
Tackle discrimination, violence and other violations of sex workers’ rights
and campaign against the repressive legal frameworks which disempower
sex workers and increase the risks they face.
◗◗ Address sex workers’ needs beyond HIV
Facilitate the self-organisation and self-determination of sex workers and
ensure that HIV programming actively challenges the structural barriers
to their health.
8
Case Studies:
Africa
Sex workers in sub-Saharan Africa have an HIV prevalence of 36.9%
(World Bank, 2013). Contributing factors to this rate are identified as
stigma from community and health service providers, violence, drug
and substance abuse, and minimal access to health services and HIV
prevention tools. There is a lack of universal access to an inclusive
package of HIV services, including reproductive health services,
unforced and anonymous HTC, appropriate treatment for STIs,
harm reduction services for drug users, and psychological support.
Furthermore, there is an overall lack of a supportive environment.
9
Case Study
1
Kenya
Bar Hostess Empowerment &
Support Programme (BHESP)
There are approximately 200,000 sex workers in Kenya, 15,000 of whom are
men. A study published in 2008 reported that sex workers and their clients
accounted for 14.2% of new HIV infections (Government of Kenya, 2008).
Legal context
The Penal Code does not focus on sex workers themselves, instead
criminalising the actions of third parties involved with sex work. However,
across the country municipal laws variously prohibit ‘loitering for the purpose
of prostitution’, ‘importuning for the purpose of prostitution’ and ‘indecent
exposure’ (Federation of Women Lawyers, 2008). These laws cause a degree
of confusion, the result being that sex workers are regularly treated as if their
work is illegal.
Issues faced by sex workers
Violence and policing
Sex workers are subjected to sexual violence, physical beatings, indiscriminate
arrest, extortion and bribery, perpetrated by their clients, police, managers or
regular partners.
Access to safe sex supplies
Condoms are in short supply and free condoms are not available in remote
areas. Government-provided condom dispensers in sex work hot spots are not
functional. Bar owners do not allow sex workers to supply condoms to their
establishments, instead maintaining a monopoly which forces sex workers to
buy condoms from them.
Access to health services
Sex workers experience poor treatment and discrimination from health care
providers and often have to pay extra for services.
10
Origins and aims of the programme
BHESP was founded in 1998 by a group of bar hostesses who doubled as sex
workers. Its leadership is comprised of a mixture of sex workers and nonsex workers, and its mission is to “influence policy and facilitate provision of
quality health services, human rights awareness, legal services and economic
empowerment for bar hostesses and sex workers” (Bar Hostess Empowerment &
Support Programme, n.d.). It has partnered with Health Options for Young Men
on HIV, AIDS and STIs (HOYMAS, founded 2011 by a group of male sex workers
living positively) to offer inclusive services for male sex workers.
Programme activities
Health promotion
BHESP promotes safe sex through peer education and community outreach.
It offers mobile and drop-in HTC and has trained 100 ‘condom ambassadors’.
It is engaged in ongoing work on improving the accessibility of condoms and
lubricants, and assisting the government in filling condom dispensers in sex
work hot spots.
Advocacy, human rights and policy development
BHESP connects with the government and funders in order to expand
discussions on human rights protection and provision of health care services.
It delivers programmes such as paralegal training, peer education and
mobilisation activities, aimed at reducing stigma, discrimination and human
rights violations, and holds consultative forums with law enforcement. It
also engages the government on an ongoing basis on the significance of
decriminalisation of sex work; sensitises security agents regarding the rights
and needs of sex workers; and is involved in policy development to ensure that
policies are sensitive to the rights and needs of sex workers.
Economic empowerment
BHESP provides innovative income-generating activities such as training,
provision of small loans, and promotion of table banking.
Challenges
In addition to the abovementioned issues, BHESP cited lack of cooperation
among sex workers as a barrier. HIV-negative sex workers discriminate against
their HIV-positive colleagues. There is also insufficient capacity to train all sex
workers on negotiation skills, which would enable them to raise their prices,
thereby reducing the number of clients they see per day and minimising their
chances of HIV acquisition.
Regional
consultative
meeting in
Nairobi
11
Best practices
Services that meet sex workers’ needs
The establishment of drop-in centres has enabled sex workers to access all HIV
prevention services including education, training, demonstration of condom
use, counselling, and HIV prevention tools including condoms, lubricants, and
nutritional supplements for those on medication.
Sex worker-led interventions
Training sex workers as paralegals, HTC counsellors and peer educators ensures
the provision of services in a friendly environment. These sex workers act as
leaders among their colleagues while at work.
Community empowerment
Sex workers are empowered to understand and know their rights, to understand
policy analysis skills, to form strong advocacy groups from the community level,
and to improve communication skills.
Engagement with the government and law enforcement
A human rights-based approach in undertaking lobbying and advocacy
activities with government and law enforcement personnel ensures recognition
of sex workers. Some police officers have started protecting the rights of sex
workers as well as helping them with distribution of condoms.
Sex workers
consultative
meeting in
Nairobi
12
Case Study
2
Cameroon
Aids ACODEV Cameroon
There are approximately 18,000 sex workers in Cameroon. The government
has not conducted research on sex work and HIV, but according to PEPFAR
(2011), HIV infection among sex workers rose from approximately 26.4% in
2004 to 36.7% in 2009.
Legal context
Prostitution and solicitation are prohibited, with sex workers facing jail
sentences and heavy fines if caught. However, some authorities tolerate
sex work.
Government agencies have perpetrated human rights abuses of sex workers
including forced HIV testing, police raids of sex work hot spots and arrests of
sex workers, and forced rehabilitation. Law enforcement officers as well as
members of the public subject sex workers to harassment, rapes (particularly
in police vehicles), beatings and extortion. Sex workers who report human
rights violations to law enforcement agencies may be arrested and detained
themselves rather than having their complaints investigated. Clients have also
raped and beaten sex workers because of real or perceived HIV-positive status
and STI infections.
Sex workers cannot access affordable and effective HIV treatment in
welcoming environments, and may be denied entry to public facilities such as
hospitals. Hospital staff often see them as undeserving of treatment for STIs
and HIV-related health concerns. Male sex workers face particular stigma and
discrimination, and the government has not developed a specific programme
to target them.
13
Origin and aims of the programme
Aids ACODEV Cameroon was formed in 2009 by sex workers and is fully
sex worker-led. It focuses on HIV and AIDS issues and needs among the
male and transgender sex worker populations. Its mission is to advocate for
the human rights of sex workers, including the right of access to medical
services, information, training and education. It also challenges all forms of
discrimination based on actual or perceived sexual orientation and gender
identity. It works with male and transgender sex workers who are left out of HIV
and AIDS prevention and management programmes.
Health promotion
‘Educational night patrols’ focus on educating sex workers about HIV prevention
approaches at sex work hot spots in Douala, Cameroon’s largest city. Peer
educators help in communicating clear messages about HTC, demonstrate
condom use, and share negotiation skills for safe sexual practices. They also
share information with fellow sex workers on health service rights to ensure
they know how to access treatment whenever they are sick. Safe sex supplies
are provided to sex workers. Care and support services are available to members
on medication, and may be extended to their homes. Support groups help
members to stick to medication and avoid taking alcohol. The organisation
partners with government hospitals and NGO hospitals that offer health
services to sex workers in welcoming medical units.
Sex workers are trained on their rights to enable them to negotiate with clients
and police.
Community consultations are carried out in sex work hot spots to design
and implement appropriate HIV programming that addresses sex workers’
needs. The organisation engages in policy review activities to ensure violence
reduction and improved prevention efforts. It liaises with rights groups and
national networks of sex workers who speak out about their situation in various
forums, holding discussions with policy makers to change oppressive laws and
policies, and targeting the media to change perceptions of sex work.
Challenges
The criminalisation of sex work in Cameroon was identified as the biggest
challenge to effective HIV programming for sex workers.
14
Best practices
Aids ACODEV Cameroon has partnered with doctors and nurses who visit sex
workers in their homes in order to provide them with health examinations and
to impart health-related knowledge.
Training peer educators is effective in reaching sex workers with HIV
prevention messages and safe sex supplies. Peer educators encourage their
fellow sex workers to learn their status at HTC centres, and encourage
HIV‑positive sex workers to seek treatment.
Forging alliances
The organisation partners with other sex worker-led organisations and NGOs
to ensure sex workers can access better treatment, care and support.
Partnership with local, regional and global sex work organisations and
networks has contributed immensely to the institutional strengthening of the
organisation, enabling it to offer appropriate services to sex workers. Through
these partnerships, the organisation is engaging in policy review activities to
ensure violence reduction and improved prevention efforts. The organisation
liaises with rights groups and national networks of sex workers who speak out
about their situation in various forums, holding discussions with policy makers
to change oppressive laws and policies, and targeting the media to change
perceptions of sex work.
15
Case Study
3
South Africa
SISONKE
There are around 182,000 sex workers in South Africa, including 8,000 male
sex workers and 7,000 transgender sex workers (South African National AIDS
Council, 2013). Sex workers constitute 19.8% of new HIV infections, and men
who have sex with men (MSM) constitute 9.2% of new infections (South
African National AIDS Council, 2012).
Legal context
Sex work is criminalised.
Law enforcement officials violate sex workers’ rights with impunity.
They violently arrest sex workers, threaten them, and sometimes rape
them. They also ask them for sex in exchange for release (Mgbako et al,
2012). Additionally, regular arrests cause sex workers to miss medication,
leading to poor treatment and defaulting.
There have been recent cases of condom and lubricant shortages, especially
in remote areas.
Sex workers face stigmatisation from health care professionals and a lack of
appropriate and inclusive health care services, which has also contributed
to their reluctance to seek treatment. The government does not offer mobile
treatment to sex workers. Law enforcement agencies and health service
providers have promoted coercive HIV testing of sex workers.
16
SISONKE was founded in 2003 by sex workers who were tired of police abuse
and harassment, unsafe working conditions, inability to access health care
and the justice system, and even inability to access banking services. Its
vision is a South Africa where sex work is recognised as an occupation, and
where sex workers’ human rights are ensured and protected. Its mission is to
bring together sex workers in order to strengthen them in the fight for their
human rights.
Health promotion
The organisation trains sex workers on HIV prevention strategies such as
appropriate condom use and the significance of male circumcision. Sex
workers who use drugs are provided with information on harm reduction and
safer injecting. Pregnant sex workers are targeted with education and training
on prevention of mother-to-child transmission. Sex workers are linked with
hospitals where they can access post-exposure prophylaxis therapy for HIV
prevention in the event of experiencing a condom burst. 24-hour mobile
services such as HTC and provision of safe sex supplies are available at sex
work hot spots.
The organisation consistently carries out consultation with sex workers. Sex
workers are trained as paralegals to help in curbing violence and the abuse
of sex workers’ rights. Human rights and health training and education is
provided to sex workers so that they can be empowered to protect themselves
from HIV, know their rights and demand access to health services.
The organisation’s decriminalisation programme seeks to convince the
government to stop criminalising sex work. It engages with trade unions and
political leaders, including the parliamentary group on health and political
parties, on the need to promote sex workers’ rights and decriminalise sex
work (Gall, 2012). The organisation works in partnership with the government
to help in addressing the issues affecting sex workers, including treatment
challenges and human rights violations. These partnerships have also
focused on sensitising law enforcement officials on the rights and issues of
sex workers.
Challenges
In addition to the abovementioned issues, SISONKE identified lack of support
from the government as a barrier to health. Although sex workers access
HTC services from mobile clinics, the government has frustrated treatment
provision through failing to offer drugs to the clinics. It has also failed to
engage community health workers to undertake defaulter tracing among sex
workers who do not adhere to antiretroviral therapy.
17
Best practices
Drop-in centres have motivated sex workers to walk in and access HIV
prevention reading materials, information and equipment.
Ensuring inclusion of all sex workers
Both HIV-positive and -negative sex workers are involved in the governance and
leadership of the organisation, enabling recruitment of more sex workers to join
the network. More sex workers are coming out to identify openly with sex work
and access HIV prevention services.
Sex workers are trained as paralegals to collect information from their
colleagues on human rights abuses and violence. They liaise with human rights
organisations which send lawyers to offer pro bono legal representation to sex
workers in court.
Engagement with sex industry gatekeepers
Training brothel managers on HIV prevention approaches and sex workers’
rights ensures that they contribute effectively towards reducing new infections,
reducing client violence against sex workers, and sharing knowledge on HIV
prevention with sex workers.
Engagement with law enforcement
The organisation has developed a working relationship with law enforcement
agencies in some areas, which invite sex workers to hold discussions with the
police on how the police could effectively help protect their rights as well as not
criminalise their activities.
18
Case Study
4
Uganda
Women’s Organisation Network for
Human Rights Advocacy (WONETHA)
It is difficult to provide targeted services to sex workers in Uganda because
of limited evidence on their numbers. The 2011 Uganda AIDS indicator
survey anticipated an increase in HIV prevalence among sex workers, from
6.4% in 2010 to 7.3% in 2014 (Ministry of Health/Uganda AIDS Commission,
2011). Furthermore, empirical evidence and anecdotal reports indicate a high
prevalence of HIV among sex workers along highways, with rates of between
21% and 35% cited in reports (Ministry of Health/CDC, 2009; Ministry of Health,
2010). WONETHA reports that every three weeks a sex worker dies from an
HIV-related complication. Sex workers’ clients and their partners constitute
10% of new infections.
Legal context
Sex work is criminalised. The HIV/AIDS Prevention and Control Bill and the
Anti Homosexuality Bill may worsen sex workers’ access to health services
(Ministry of Health/Uganda AIDS Commission, 2011).
Policing and violence
The AIDS epidemic has added another layer of stigma and discrimination
against sex workers, with them being blamed for spreading the virus to the
rest of society. Many experience violence on the streets at work and in their
personal lives. Sex workers are subjected to coercive testing, harassment,
beatings and unnecessary arrests.
Screening services are expensive and sex workers face challenges in accessing
them. Illegality and stigma have led to the neglect of sex workers by health
care professionals, along with poor health-seeking behaviour by sex workers
themselves. Services are patchy with poor coverage and poor coordination.
Poor condom use, unsupervised abortions and low compliance with and
adherence to medication are among the challenges to sex workers’ health.
19
WONETHA was founded by sex workers in 2008 as a response to the repeated
harassment, insults, stigma, discrimination and arrest without trial by law
enforcement agencies that they faced in their work. Its mandate is to improve
the health, social and economic wellbeing of sex workers in Uganda.
Health promotion
The organisation works with and for sex workers to promote their healthseeking behaviour and safe sex practices through health education outreach,
psychosocial support counselling, provision of voluntary counselling and
testing (VCT), and delivery of reproductive health services. Its HIV prevention
programming has focused on educating and training sex workers on HTC,
demonstration of condom use, and negotiation skills. It provides safe sex
supplies to sex workers and conducts outreach activities which create
awareness of sex workers’ health rights and sexual and reproductive health
education.
The organisation documents human rights violations, and engages in advocacy
to oppose both the coercive testing of sex workers and the criminalisation of
sex work that limits their opportunities to access treatment. Specific advocacy
programmes oppose violations of sex workers’ rights by clients, the public, and
law enforcement agencies. Campaigns challenge stigma and discrimination
perpetrated against sex workers by their families, partners, and the public.
Advocacy initiatives seek to influence leaders to ensure sex workers are
included in diverse economic empowerment programmes by the government.
Challenges
In addition to the issues listed above, an absence of data on the number,
attitudes, and behaviour of sex workers has affected health and rights
protection programming that targets sex workers. Additionally, many funding
agencies do not want to fund sex worker organisations.
20
Best practices
Dissemination of HIV prevention tools and information, education and
communication materials empowers sex workers and raises awareness of
HIV infection and how to live a free, dignified and healthy HIV-positive life.
Sex workers are referred to sex worker-friendly clinics for free and
welcoming services that enable them to access medication.
Sex worker peer educators conduct continuous routine follow-ups for HIVpositive colleagues to ensure they are supported and to gather feedback for
better quality HIV/AIDS-related services, to measure progress towards the
advocacy objectives and to determine what has been achieved.
Community mobilisation and sensitisation provides sex workers with
the skills needed to demand quality services and access to care. In its
health advocacy, the organisation creates support among sex workers’
communities and generates demand for government health policies that
affect them, and the removal of discriminatory laws.
Capacity building workshops and training assist with the provision of
practical information and opportunities for information sharing among sex
workers to raise awareness of the health and welfare needs of HIV-positive
sex workers. They also enable empowered and skilled HIV peer educators to
demand quality services.
Forging alliances
Networking with civil society organisations benefits sex workers who
receive training on HIV prevention, treatment, care and support and sex
workers’ rights.
A focus group
discussion in
Uganda
21
22
Case Studies:
Asia and the Pacific
23
Case Study
5
Thailand
SWING Foundation
There are around 3,000 female and 3,000 male Thai sex workers in the beach
resort of Pattaya, with an additional 20–25 female migrant sex workers. The
government of Thailand has adopted a strategic approach to HIV/AIDS. The
United Nations Development Programme stated in 2004 that Thailand was
one of the very first countries to achieve the sixth Millennium goal, to begin
to reverse the spread of HIV/AIDS by 2015, well in advance of the target date.
Policing
Although SWING reports a good rapport with police, there are nonetheless
roundups of ‘freelancers’ (sex workers at beaches), and possession of condoms
is used as evidence of trafficking.
Thai citizens have access to cheap health care (seen as ‘free’ or heavily
subsidised) at government hospitals and clinics, but this does not apply to
migrants, and private clinic charges are high.
The SWING Foundation is a community-based organisation founded in 2004,
with branches in Pattaya and Koh Samui. It provides care and support for sex
workers, including VCT, outreach, drop-in centres and awareness campaigns.
Health promotion
The organisation’s drop-in centres
enable sex workers to participate
in safe sex awareness sessions in a
safe space. VCT services in SWING’s
Pattaya drop-in centre are managed
in collaboration with Sisters, a
partner organisation which assists
transgender sex workers.
24
SWING provides educational opportunities for sex workers, including English
language classes, non-formal education and vocational training.
Challenges
It can be hard to gain sex workers’ trust as providers of quality health care, as
they view SWING either as a community-based NGO or as their friends, rather
than professional medical staff.
HIV-positive sex workers fear losing their jobs if their status is disclosed, so they
often refuse to receive any services for people living with HIV and AIDS. It is a
challenge to ensure they receive continuous treatment.
Migrant sex workers are unlikely to obtain HIV testing if no welfare services
are on offer should they test positive. Coordination is required with related
groups, organisations and networks to provide antiretroviral drugs to them.
HIV-positive sex workers require assistance in accessing appropriate medical
treatment free of charge.
More activities are needed for migrant sex workers.
Thai male and transgender sex workers require assistance with their hospital
registration transfers for Thailand’s Universal Access Programme coverage so
that they can access appropriate services if they become HIV‑positive.
Funding sources are a concern for the programme.
Best practices
Outreach activities are the strength of the VCT clinic as they build rapport
with the community and disseminate information and education. Workshops
increase sex workers’ knowledge about VCT.
An anonymous (or coded) system is preferred by sex workers for testing. Clinic
staff carry out monitoring of service user adherence to antiretroviral therapy.
Risky behaviour of sex workers is monitored and attempts at reducing it are
made by counsellors and outreach workers.
Counselling can be done by telephone.
Transportation costs from/to the clinic should be reimbursed. Female sex
workers are given transport allowances. T-shirts given out for free make good
incentives for accessing VCT services.
Smooth and effective service delivery
Mapping of sex workers in the district helps outreach workers reach out to the
community. Information is regularly updated during (de)briefings.
A safe dossier system
has been introduced in
anticipation of an overload
of clients. Client files
(similar to patient health
files kept by doctors)
enable the updating of
information (such as
CD4 count) and ensure
appropriate services
are delivered.
SWING Centre
25
Case Study
6
India
Karnataka Sex Workers Union
(KSWU)
KSWU is a trade union for sex workers of all genders in Karnataka, India,
established in May 2006 and affiliated to the New Trade Union Initiative, which
is the national federation of independent trade unions. It is democratically
run by sex workers and all its members and office bearers are sex workers.
Previously, no community-based or non-governmental organisation
was working in crisis intervention in Karnataka for female sex workers.
Community-based HIV organisations focused on condom distribution and
health care, but when a sex worker was in crisis, there was no one to help.
KSWU addresses this gap in services.
KSWU liaises with local government bodies to ensure access to welfare
schemes and entitlements.
Access to justice
The union provides access to legal
assistance for matters arising from
sex work, organises sex workers to
secure fair treatment and humane
conditions in their work and lives,
and assists in the resolution of
work-related disputes.
26
KSWU provides assistance for children of sex workers and their families, with
facilities for educational, cultural, social, political and economic development,
and provides support in the event of sickness, unemployment, old age,
accident or death.
Challenges
It can be difficult to attract sex
workers for membership, and
retain membership, due to their
spread-out nature.
It can be difficult to bring sex
workers together on a ‘sex work is
legitimate work’ platform.
The union lacks proper finances.
Best practices
Strong and quick crisis intervention provided by the union has created a deep
trust among the members that there is someone to come to their rescue.
Crisis teams are well spread-out and well trained to deal with the police, hired
criminals and other elements.
Funding sources that prioritise sex workers
Rather than receiving funding from an external agency, KSWU receives
monthly fees from its members, making it accountable to the community and
answerable to those people who pay fees.
Union members said that their
work was like any other dhanda
(work) and they deserved dignity
and respect as workers.
27
Case Study
7
Malaysia
Transgender programme
of PT Foundation
Legal context
Sex work is criminalised, although the laws only apply to women. Transgender
female sex workers are not recognised as women, but although they are not
prosecuted for sex work, they may be subjected to arbitrary detention for
public indecency. Rape laws do not apply to post-operative transgender women.
Additionally, sharia laws which apply only to Muslims penalise transgender
Muslim sex workers for being ‘men posing as women’, regardless of their
transition status. These laws predominantly affect Malays, who comprise the
majority of PT Foundation’s transgender service users.
Sex workers are vulnerable to arbitrary detention for carrying more than three
condoms, as the number of condoms in possession is seen as corresponding to
the level of promiscuity.
Corrective interventions
The Department of Islamic Development (JAKIM), a religious policy-making
department, has implemented the ‘Mukhayyam Programme: Employment
Training Programmes for Most at Risk Populations’, particularly for transgender
Muslims. It aims to remove transgender people from sex work and economically
empower them, but is very corrective in nature, with participants also expected
to undergo religious and spiritual lessons and boot-camp training.
Systemic exclusion
Post-operative transgender people have difficulty in changing their official
documents to correspond to their true gender.
Access to health care
Gender reassignment surgery was banned for transgender Muslims, but as a
result it is no longer available to any transgender people in Malaysia.
28
PT (Pink Triangle) Foundation is a community-based organisation providing
HIV and STI-related services to the most at-risk populations. Its transgender
programme was established in 1992, and is now aided by the Ministry of
Women, Community and Development. The programme is led by women,
including transgender women and sex workers. The managers of both the
transgender programme and the sex worker programme are transgender.
Health promotion
The organisation provides condoms and voluntary HIV testing and counselling
at its drop-in centre near the red-light areas.
In 2010 the transgender programme founded MyNETRA, a closed FB group
exclusively for trans* people (encompassing the broader transgender community
to include those with non-binary identities), which has 2,000 members all
over Malaysia and provides accurate information on news. MyNETRA goes
some way to filling the gap left by funding cuts. Transgender community
empowerment workshops are held in collaboration with sexuality rights festival
Seksualiti Merdeka.
The programme is actively involved in advocacy efforts, namely with
government agencies working on HIV-related matters. MyNETRA supported the
transgender women in the state of Negeri Sembilan who filed a judicial review
of the ‘crossdressing’ sharia law. The programme collaborates and networks
with Legal Aid centres, and is involved with the ‘I Am You: Be A Trans Ally’
campaign on social media.
Challenges
Although the programme is essentially government-funded, the state is a
barrier in providing holistic services to the transgender sex worker community.
Its sole focus on achieving targets and numbers has blinded it to the fact that
members of the target group operate within a hostile environment rather than
one which enables them to seek out services.
Condoms funded and distributed by the Ministry of Health are nonetheless used
as evidence by police to detain sex workers.
Recent government funding cuts for HIV prevention through sexual
transmission have left many social workers from the community jobless.
Funding sources are a concern for the programme.
Best practices
Services that meet
sex workers’ needs
Although no longer
in operation, the VCT
clinic also provided
hormone replacement
therapy, which drew
transgender people to it:
a good example of the
provision of relevant
and desired services.
29
Networking skills allow the transgender programme to expand its work
beyond the HIV/AIDS paradigm. Social media is used to reach out to members
of the community and to organise community events. Facebook is an effective
advocacy tool.
MyNETRA shifts focus away from PT Foundation, which is beneficial in terms
of security.
Funding sources that prioritise transgender people
Transgender people of many trades have been effective in mobilising resources
within the community for events and campaigns, reducing financial cost.
Engagement with the government
The transgender programme engages in consistent networking and
consultations with government agencies, even if they are not as forthcoming.
The team feels it is still important to be involved in the conversations, and to
reduce harm to the transgender community wherever possible.
Forging alliances
Networking and collaboration with different groups has enabled PT Foundation
to mainstream transgender issues and reach a wider range of people.
30
Case Study
8
Myanmar
AMA
Most services aimed at sex workers are concentrated in urban areas, putting
rural sex workers at a disadvantage. Prior to AMA’s establishment, there was
no programming aimed at transgender sex workers in Myanmar, and MSM
programming did not meet male sex workers’ sex work-specific needs.
Now more commonly known as AMA, the National Network of Sex Workers, an
independent network which is fully sex worker-led, was founded in 2007 and
works for sex workers of all genders. The name ‘AMA’ was chosen as a strategic
move to improve the chances of getting registered. It means ‘big sister’ in
Burmese and is an acronym for the literal translation of ‘sex worker’ – ‘Aye Mya
Ayake’. It was set up to become a self-determining, representative entity, and
works in the field of HIV/AIDS and sexual and reproductive health.
Health promotion
Peer educators conduct outreach and are trained in HIV and STI education,
reproductive health information, basic counselling skills and using teaching
aids and games. Safe sex supplies are distributed and referrals made to the
National AIDS Programme and
local and international NGOs
for HIV pre- and post-test
counselling, STI diagnosis and
treatment. The organisation
enables access to antiretroviral
therapy for HIV-positive sex
workers. An apartment in
Yangon accommodates HIVpositive sex workers who must
come to the city for treatment,
31
and staff members support them throughout the entire process. Incarcerated
sex workers are assisted with access to antiretroviral therapy, nutrition support
and medication for opportunistic illnesses. Home-based care, nutrition support
and nursing is provided to HIV-positive sex workers.
The government engages with AMA and they undertake work together related
to HIV and sex work. AMA has trained sex workers in leadership, advocacy and
empowerment.
The organisation assists sex workers in opening bank accounts, a milestone
which is significant given that Myanmar’s banking system is still being
established.
Challenges
Accessing funds to run as a network is difficult when only money for
programming is available.
Although the name ‘AMA’ was a strategic choice to improve the organisation’s
chances of getting registered, registration had not yet been successful at the
time of writing, with a lengthy application process.
Best practices
Funding sources that prioritise sex workers
Programming should focus on the needs of the community, rather than
succumbing to the orders of international NGOs.
Forging alliances
Community cohesion is an important element of building a national network
from the ground up. Intricate networks of sex workers (both locally and
internationally), health professionals, United Nations players, international
development, feminists, and other key affected populations (in particular key
affected women) all play a part.
32
Case Studies:
Europe
Multiple region-wide issues are identified as factors contributing to
sex workers’ vulnerability to HIV, including laws criminalising and
penalising sex work, whether directly or indirectly; an absence of
safe and supportive working environments; discriminatory attitudes,
abuse, and other forms of violence against sex workers by law
enforcement officers, clients, the media and the general public; the
insufficiency, inaccuracy or even failure of public health efforts to
provide the most vulnerable populations with accessible, appropriate,
and acceptable HIV programming; information and services
which fail to address the needs of the most socially invisible and
hard‑to-reach communities of sex workers, namely indoor‑based,
male, transgender, and migrant sex workers; the failure of HIV
programmes and services to respect sex workers’ rights to privacy,
dignity, informed consent, and freedom of choice; and laws
criminalising HIV non-disclosure, exposure, and transmission.
33
Case Study
9
Kyrgyzstan
Tais Plus
97% of sex workers working in the capital, Bishkek, are Kyrgyzstani, but 75% of
them come from other regions of the country and 60% are without identification
documents and registration. HIV prevalence among sex workers in Kyrgyzstan
increased from 1% in 2008 to 3.4% in 2010 (European Centre for Disease
Prevention and Control, 2013). Furthermore, 16.7% of male and transgender sex
workers in Kyrgyzstan are believed to be HIV‑positive. However, in Bishkek,
Tais Plus reports that HIV prevalence among sex workers is at 0%.
Legal context
Sex work is neither a crime nor an administrative offence, although in the past
decade the government has attempted to introduce legislation penalising it on
both counts.
Photo: Tais Plus
Sex workers experience violence at the hands of law enforcement officers on a
daily basis, who target them with threats, blackmail, psychological violence, and
extortion (Sex Workers Rights Advocacy Network, 2009; Tais Plus, 2012a). During
frequently unlawful police raids, sex workers are illegally detained under the
guise of hooliganism, drunkenness, or vagrancy, robbed, forced to give bribes,
and in some cases subjected to mandatory HIV testing. Footage from police
raids is often screened on
state television and in online
media, publicly shaming sex
workers and putting them
at risk of being recognised
by their families and in
their local communities.
Tais Plus members commemorating
the International Day to End
Violence Against Sex Workers
– 17 December – on the streets
of Kyrgyzstan’s capital.
34
The government’s attempts to penalise sex work have further increased sex
workers’ stigmatisation and heightened their risk of experiencing violence and
other human rights violations.
Widespread discrimination persists in state and non-governmental institutions
meant to provide support and protection for the most vulnerable populations.
These include health care clinics and social service providers. Health care
professionals exhibit discriminatory and judgemental attitudes, and clinical
services come at a high cost. Restrictive regulations on both internal and
external migration and civil status, requiring every individual to obtain official
registration in a particular region of the country, further deprive migrants, who
comprise the vast majority of sex workers in Kyrgyzstan, of access to medical
insurance and primary health care services, including HIV testing, treatment,
and care.
Access to social services
Because many internal migrants in Kyrgyzstan are without documentation,
they do not qualify for many social services, as well as family allowance and
other forms of financial crediting.
Tais Plus is one of the first sex worker-led organisations in the region. It
was formed in 1997, officially registered in 2000, and contributed to the
establishment of the first Kyrgyzstani network of sex workers, Shah-Aiym, in
2010. Tais Plus works with sex workers of all genders, their partners, children,
and clients in Bishkek and its surroundings, contributing to a remarkably low
HIV prevalence among sex workers in the capital.
Health promotion
Photo: Tais Plus
Above all, Tais Plus focuses on promotion of consistent condom use. It delivers
tailormade outreach ‘mini-sessions’ dealing with topics such as HIV infection,
STIs, sexual and reproductive health, tuberculosis, and risks associated with
alcohol and drug use. The organisation provides referrals and accompaniment
to medical and support services that are confidential, non-judgemental, mostly
free, respectful, and accessible to all regardless of nationality, and it constantly
monitors their quality. Pre- and post-testing counselling is available to sex
workers visiting the local AIDS centre, including individual risk assessment,
education about safe sexual behaviour, the development of HIV risk reduction
plans, support, and (if needed) referrals to medical clinics. Tais Plus also offers
mouth-swab HIV tests and peer counselling in its drop-in centre, where a
doctor and psychologist are
available for consultation.
Its 2008 HIV prevention
project aimed at clients
(subsequently closed due
to shortage of funding)
provided them with safe
sex supplies, education
and health care referrals.
‘Dolls action’ conducted
by Tais Plus in 2012.
35
The organisation engages in advocacy for sex workers’ rights in medical
settings and sensitisation of health care personnel. It documents violence
against sex workers and takes part in parliamentary meetings, roundtable discussions with government officials, and public hearings across
the country. It provides sensitisation trainings for the representatives
of law enforcement agencies, and successfully campaigned against the
government’s criminalisation of sex work.
Access to justice
Sex workers visiting the organisation’s drop-in centre can meet with a lawyer.
Additional topics covered by Tais Plus’ outreach ‘mini-sessions’ include
sex workers’ rights and freedoms, violence, discrimination, and obtaining
registration and an identity card. The organisation offers assistance in
obtaining identification documents, housing, and health insurance, referrals
to other facilities and services, and non-judgemental psychological support
in case of emergency and crisis. Additionally, sex workers can access
laundry, shower, kitchen and internet facilities. Emergency accommodation
is available in the drop-in centre for up to two weeks, though in some cases
pregnant, severely ill and highly vulnerable sex workers (along with their
children) have lived on the premises for several months. Tais Plus overcomes
sex workers’ isolation by bringing them together in a community space for
different activities.
Artistic installation depicting the work environment of outdoor sex workers in Bishkek,
prepared by members of Tais Plus to commemorate the International Day to End Violence
Against Sex Workers in 2013.
36
Case Study
10
Macedonia
STAR-STAR
HIV prevention projects aimed at sex workers rely on street-based outreach,
reaching only 13% of the target population.
Legal context
Sex workers receive excessive fines of €600 –800 under administrative laws
against selling sexual services, loitering, and hooliganism. Third parties
profiting from sex work are criminalised, including those providing space for
sex work, who are frequently sex workers themselves.
Sex workers are regularly targeted by the police during sweeps aimed at
eradicating sex work from the public sphere. Police confiscate condoms and use
them as evidence against them. They face stigma, hostility, and violence from
clients, police, the general public and the media.
Discriminatory treatment against sex workers is widespread, including in
medical clinics and institutions providing social services, deterring them from
filing complaints or seeking support in cases of abuse and illness. The threat of
arrest for supposedly intentionally spreading infectious diseases deters them
from accessing HIV-related services. Judgemental and hostile attitudes towards
male and transgender sex workers in medical settings lead to violations of the
right to confidentiality, and even refusals to provide medical services.
STAR-STAR is the only sex worker-led organisation in the country, founded in
2008 and registered in 2010 as an ‘Association for the Support of Marginalised
Workers’. It protects and promotes sex workers’ rights and fights against the
discrimination and stigma faced by sex workers on a daily basis. It advocates
for a change in both the repressive legal framework and negative social
attitudes toward sex work.
37
Health promotion
The organisation engages in interventions addressing sex workers’ access to
high-quality health services (including HIV counselling and testing, treatment,
care and support), free from coercion or discrimination, and available regardless
of the changing funding environment. It provides indoor-based sex workers with
safe sex supplies and education on HIV and other STIs, safe sexual behaviour,
issues related to sexual and reproductive health, and occupational safety.
It delivers training in consistent condom use and negotiation with clients.
Referrals are made to medical services, including HIV testing, STI check-ups,
gynaecological and dermatological counselling, and free harm reduction
programmes. An online register of ‘Friendly Health Centres’ is planned which
will direct male and transgender sex workers to respectful and non-judgemental
HIV-related services.
STAR-STAR seeks to develop sex workers’ collective capacity to effectively
engage in the struggle for their own rights and improvement of their legal
and social situation, through advocacy campaigns and involvement in policy
development processes. It makes efforts to ensure the sustainability of HIV
programming for sex workers in the changing funding conditions, through
community involvement and the diversification of funding sources so as not
to solely rely on grants from one source. Sensitisation trainings are carried
out for health workers, including medical specialists, general practitioners,
and nurses operating in health care clinics which offer HIV-related services
to members of marginalised communities. These trainings are led by male
and transgender sex workers, some of them living with HIV, and facilitated by
trusted health professionals and human rights activists. The organisation is also
involved with public campaigns such as marking the International Day To End
Violence Against Sex Workers on 17 December, and produces an online monthly
magazine available to members of the public.
Best practices
Photo: STAR-STAR
Informal and sociable outreach plays an essential role in overcoming the
isolation and marginalisation faced by indoor-based sex workers.
STAR-STAR advocating for sex workers’ labour rights on the International Workers Day, 1 May.
38
Case Study
11
Sweden
Rose Alliance
Legal context
Sex workers’ clients are criminalised, as are third parties profiting from sex
work, which includes not only managers but hotel managers, sex-ad website
owners, and even taxi drivers. The law, known globally as the Swedish model
or the Nordic model, is based on a perception of sex workers as victims of male
domination, and is intended to eradicate sex work. The NSWP’s briefing paper
on the criminalisation of clients covers this in more depth.
Criminalisation of clients has driven sex work underground, forcing those
selling sexual services to operate in frequently unsafe or unfavourable working
conditions and exposing them to violence and harassment.
State-funded condom distribution is limited to only two cities in the country
because harm reduction efforts are frequently considered to be facilitating and
legitimising sex work.
Sex workers experience stigmatisation and discrimination at the hands of
social service providers and health care professionals, who often actively
encourage exit from sex work or only offer assistance to those who declare a
willingness to cease selling sex. The vast majority of sex workers do not reveal
their occupation and may not even visit HIV-related services, so as to avoid
patronising and discriminatory treatment. Restrictive laws on HIV exposure,
non-disclosure, and transmission effectively criminalise sex workers living
with HIV and discourage HIV testing out of fear of arrest and imprisonment.
Access to housing
Sex workers are at risk of losing their homes because landlords are forced to
terminate leases or evict their tenants if they discover – or even suspect – that
the tenants are selling sexual services.
39
Rose Alliance, the ‘National Organisation for Sex and Erotic Workers’, was
established in 2009 and brings together current and former sex workers to
advocate for their rights and an end to stigma around sex work. It was initiated
in response to the emergence of the Swedish model and seeks to regain sex
workers’ agency and credibility in the public sphere.
In 2012 Rose Alliance, together with its partner, HIV Sweden, was granted
funding by the Swedish Institute for Communicable Disease Control to
introduce the first nationwide HIV prevention programme dedicated to
sex workers in Sweden, designed, implemented, and evaluated entirely by
members of the sex worker community. Its objective is not only to effectively
increase sex workers’ knowledge about HIV and STIs, but also to overcome
the stigma and discrimination which constitute the main barriers to sex
workers’ access to HIV-related services. It uses the internet to connect with
sex workers working in Sweden, which is
the means of communication preferred
by the vast majority. Rose Alliance has
also recently trained peer educators
in HIV/STI prevention, occupational
health and safety, private sexuality and
emotions, health care and drug use,
and the specificity of social services in
Sweden, as well as different practical
skills necessary in outreach work. The
organisation’s website is intended to
serve as a repository of information
relevant to sex workers, including
health‑related information.
Photo: rose alliance
Health promotion
Advocacy, human rights
and policy development
Photo: Mathilda Piehl
The organisation aims to improve health
and social services for sex workers in
Sweden through the use of its website,
which will be used to raise awareness of
sex workers’ rights among health care
staff and social service professionals,
shedding light on common problems
faced by sex workers – including migrants
and those who use drugs – in different
medical settings and social security
institutions, in order to improve the
quality of their services and overcome
discriminatory attitudes and stigmadriven practices.
Rose Alliance advocating for
sex workers’ rights at the Pride
Parade in Stockholm, 2012.
40
Community-led workshops and informal one-on-one meetings enable
community members to provide one another with emotional support
and overcome their loneliness and isolation resulting from unfavourable
working conditions. These gatherings also play an important role in
community strengthening.
41
The organisation fosters
mobilisation and the
strengthening of the sex
workers’ community in
Sweden by providing its
members with peer education
and support and by making
sex workers’ voices heard
and taken seriously in public
debates on ‘prostitution’,
health, and human rights.
It raises public awareness
about sex workers’ situation
in Sweden and addresses
discriminatory laws and
social attitudes severely
affecting sex workers’ living
and working conditions.
It cooperates closely with
different organisations
fighting for the rights of the
most stigmatised – and in
some cases, overlapping
– communities; advocates
state prioritisation of sex
Rose Alliance commemorating Jasmine,
workers’ health; and demands
community member and sex workers’ rights
unconditional access for sex
activist brutally murdered in July 2013.
workers to much needed
harm reduction programmes.
It conducts sensitisation
training sessions for health care professionals on sex workers’ rights, the
difference between sex work and trafficking (very often conflated in medical and
social service settings), the negative consequences of the current legislation on
sex workers’ physical and sexual health and safety, and so on. Rose Alliance is
building a network of reliable journalists, politicians, academics and allies able
to advocate for sex workers, and provides the general public with actual and
unadulterated knowledge. It has established an award for those contributing to
the struggle against the violence, stigma and discrimination experienced by sex
workers in Sweden.
Case Study
12
Russian
Federation
Silver Rose
There are estimated to be between 1 and 3 million sex workers in the Russian
Federation. HIV rates are believed to be at 15% among male and transgender sex
workers, and 12.9% among indoor sex workers in St Petersburg. HIV prevalence
in Russia has risen by 250% since the beginning of the 21st century, with more
than 750,000 people living with HIV and AIDS. The withdrawal of the Global
Fund to Fight AIDS, Tuberculosis and Malaria in 2010 and the state restrictions
preventing non-governmental organisations from obtaining foreign funding
have significantly limited the scope and number of HIV prevention projects
dedicated to sex workers nationwide. The most optimistic estimates indicate
that 2 to 3% of sex workers were reached by any kind of HIV prevention and
education efforts in 2012 (Conecta, 2012).
Legal context
Sex work is partially criminalised. ‘Prostitution’ is an administrative offence,
while profiting from ‘prostitution’ is punishable under the Criminal Code.
The ‘promotion of homosexuality’ is banned, as is substitution treatment
for people who use drugs. HIV transmission and exposure is criminalised.
There are repressive migration laws, and migrants are deported once they are
diagnosed with HIV.
Sex workers are deprived of rights, protection, and the ability to organise. There
is a high level of police-driven violence and harassment against sex workers.
Frequent raids and sweeps see sex workers not only illegally detained and
arrested but also humiliated, blackmailed, beaten, tortured, brutally raped,
and even murdered. They additionally face harassment and coercion by other
parties, such as managers, organised crime networks, and clients, while there is
a climate of impunity for perpetrators.
42
Access to health
and social services
Due to high levels of internal
(intra-regional) and external
migration (the latter group
mainly coming from former
Soviet republics), over 70%
of sex workers working in
the Russian Federation lack
the required registration
and medical insurance, and
as such are excluded from
health and social services.
Through Silver Rose’s website, developed in 2012,
sex workers can consult with a peer psychologist,
lawyer or health-care professional.
Silver Rose was established in 2004 as a community support group based in St
Petersburg. It is a ‘non-commercial partnership of sex workers and their allies
to protect sex workers’ health, dignity, and human rights’. A main goal is the
decriminalisation of sex work, as well as the creation of a political and social
environment granting sex workers safe working conditions and providing them
with equal access to health care and justice. Silver Rose welcomes sex workers
of all genders, sexual orientations, work settings, ethnic origins, and citizenship
status, as well as other stakeholders who share its values and commitment to
fighting for the improvement of sex workers’ situation, including lawyers, rights
activists, medical professionals, clients, and administrators of sex work venues.
It is still not recognised as a legal entity by the Russian state: the Ministry of
Justice denied its registration, claiming that in its charter the organisation refers
to a vague category of sex work, not listed in any classification of occupations
in the Russian Federation, and thus the Ministry cannot verify that the
organisation will not violate the constitutional ban on “propaganda or agitation
instigating social, racial, national or religious hatred and hostility”. No legal
recognition means Silver Rose cannot receive any state or foreign funding.
Health promotion
The organisation conducts informal outreach, providing sex workers with safe
sex supplies and education on HIV and other STI infections. Peer outreach
workers target managers, administrators, and owners of sex work venues with
information on occupational health and safety in the context of sex work, and
encourage them to provide sex workers with easy access to safe sex supplies.
Often those third parties become gatekeepers by referring sex workers to Silver
Rose, or inviting peer educators to carry out workshops on their premises on HIV
prevention and negotiation of condom use. Access is facilitated to acceptable
and affordable HIV-related services, specialist medical care and support, the
organisation having developed an unofficial memorandum of understanding
with trusted and sensitised health care professionals from different services,
including HIV and STI testing and treatment, gynaecological counselling,
and drug and alcohol treatment, all offered within a non-judgemental and
non‑discriminatory framework. Crucially, the majority of these services are
accessible and provided for free to a large number of migrant sex workers who
do not have the required registration and/or compulsory health insurance.
Additionally, sex workers can communicate online with a gynaecologist
and peer psychologist. Community-led HCT is delivered anonymously and
voluntarily by trained peer counsellors, and instant referrals made for sex
workers diagnosed with HIV. HIV-positive migrant sex workers, who are legally
at risk of deportation, may be connected with sensitised medical centres and
sex worker-led organisations in their home countries.
43
Access to justice
Silver Rose carries out careful and systematic documentation of police-driven
harassment and other forms of violations of sex workers’ rights, gathering
detailed information on patterns of violence experienced by sex workers in the
Russian Federation, and providing sex workers with adequate legal support
during court cases and trial procedures. Data on police-driven violence faced
by sex workers has been used to develop a series of mini-seminars entitled
‘Know Your Rights’ which cover current legislation on sex work in the Russian
Federation, laws on migration, registration and drug use, sex workers’ civil and
human rights, and – most importantly – procedures of action during (illegal
or arbitrary) police raids and arrests. Presently the organisation is working
on a short video to increase sex workers’ legal literacy and present effective
strategies of legal self-defence in cases of police harassment and detention.
The organisation conducted research on HIV prevalence among sex workers
working indoors in St Petersburg, which was published in a scientific journal
issued by the Russian Academy of Medical Sciences. As well as being an
important source of knowledge, this doubled as an advocacy tool calling for the
implementation of comprehensive, state-funded HIV programming for indoorbased sex workers. More research is to come, conducted in accordance with
international human rights standards and in a respectful and non-coercive
manner. The sex worker community is becoming increasingly visible in the
media and the public sphere. The organisation cooperates with trusted and
sensitised journalists willing to overcome the widespread discriminatory
attitudes towards sex workers in Russian society and to highlight their
real problems in the era of the HIV pandemic. It holds public gatherings,
performances and press conferences, to draw attention to themes such as the
International Day to End Violence Against Sex Workers on 17 December. In
December 2013 it planned an exhibition of art created by sex workers during one
of its community workshops, followed by a charitable auction, the profits from
which to be used to purchase HIV prevention materials for distribution during
community-led outreach.
Photos: Silver rose
Representatives of Silver Rose participate in a training session on leadership in Lviv, 2013.
44
Case Studies:
Latin America
Although each of the countries studied has free services aimed at
addressing sexual health, HIV/AIDS and STIs, these are aimed at
the general public, with gaps remaining in meeting the needs of
sex workers, particularly in terms of flexible schedules and quality
care. Health services are not respectful of sex workers’ rights and
there is a lack of sensitive, warm and respectful care programmes.
Sex workers are also affected by shortages of medication and a
scarcity of rapid
testing services,
as well as of
both male and
female condoms.
There is widespread
ignorance and a general
lack of information among
health care professionals,
which contributes to
homophobia, discrimination and
aggression. Service providers often
make value judgments in the sense of
encouraging sex workers to abandon
their profession because of moral or
religious concepts. Health services
suffer from poor structure and a lack of
professionalism, and there is no clear
response to complaints, let alone
changes in health policy.
The Latin America report notes that,
although interviews were conducted
with those responsible for health and
HIV and STI programmes, “it was only
sex workers themselves who mentioned
prejudice, stigma and specific needs such
as opening hours, provision of information
on prevention and comprehensive health
care, availability of contraceptive methods
and a comprehensive service to treat
transgender sex workers.”
45
Case Study
13
Ecuador
La Sala (The Room)
Policing
Sex workers operate in a hostile environment and are persecuted by police.
In addition to shortages of condoms, sex workers are unable to negotiate their
use with clients.
Sex workers face exclusion from health care services.
La Sala ran between April 1998 and May 2005 and was created to promote
empowerment and self-care for sex workers, thereby reducing the incidence of
HIV/AIDS in the province of El Oro. It aimed to build and design methodologies
for HIV/AIDS prevention and condom use with the active participation of
female sex workers. It prioritised experiential and reflective learning of sex
workers in an atmosphere of trust.
Health promotion
La Sala broadened sex workers’ knowledge of safe sex practices. It also tackled
internalised feelings of rejection, through building self-esteem and expressing
feelings, and looked at ways to counter the negative social messages that
caused sex workers to love themselves less and consequently take less
care of themselves. It provided tools to empower sex workers, starting with
negotiation skills for female sex workers to use with their clients and partners.
Its comprehensive, holistic health approach emphasised prevention and
encouraged sex workers to take personal responsibility for their own health
and well-being.
46
Female sex workers have organised
changes to public policies and
health care service policies.
Challenges
Mistrust and stigma were
sometimes a barrier to getting
female sex workers involved.
Best practices
Services that meet sex
workers’ needs
Sex workers were provided
with reliable information on
safe sex practices and ways to
negotiate with clients, correcting
misconceptions about condom use.
A consistent group of volunteer
sex workers empowered their
colleagues to handle arguments
with clients and partners in favour
of condom use. A positive change
was observed in terms of the
prioritisation of their health over
pressing financial need.
Sex workers increased their self-esteem, acquired tools for strengthening
solidarity and were empowered to propose unions and strategies.
Forging alliances
Solidarity was achieved with women’s and feminist organisations, as well
as other civil organisations.
Engagement with health service providers
Sex workers organised changes to public policies and health care service
policies, regarding the regime of control of so-called ‘prostitution’ in the
country, and the dehumanising conditions and precariousness of attending
health services.
The programme has been replicated in other cities and other countries.
47
Case Study
14
Mexico
Male sex worker programme
of CHENACA.C
The state claims a lack of resources which prevents it from providing safe sex
supplies to sex workers, though it is believed that a lack of political will is also
to blame.
Slow bureaucratic processes and medicine shortages constitute obstacles in
accessing services and care.
CHENACA.C (Men’s Collective in Community Action) is an organisation linked to
the Global Network of Sex Work Projects. Its male sex worker programme, which
ran between February 2010 and December 2012, worked at reducing the number
of new infections, as well as the effects of HIV/AIDS and other STIs, through the
development and implementation of strategies and preventive actions, based on
scientific evidence specific to male sex workers and their clients.
Health promotion
The organisation delivered HIV/AIDS and STI workshops, providing educational
materials for sex workers and informing them on correct use of condoms and
water-based lubricants. It referred them for medical care free of discrimination,
and to Popular Insurance, which afforded them access to free health services.
It also provided free HIV testing with pre- and post-test counselling.
48
Challenges
It was difficult to gain the trust
of male sex workers, and often a
great deal of time was needed to
convince them.
Funding still has not been
obtained for replication of the
project in other states.
Best practices
Services that meet
sex workers’ needs
The use of workshops in
imparting knowledge to sex
workers was successful in
enhancing their, and by extension
their clients’, awareness about
sexual health and prevention
of HIV and STIs.
49
Case Study
15
Mexico
Transgender sex worker
programme of Tamaulipas
Diversity VIHDA Trans A. C.
Transgender people in Mexico experience stigma, discrimination, rejection,
police violence, sexual exploitation and exposure to risks on a daily basis just
by leaving home to go to work, including but not limited to sex work.
It is rare for transgender people to visit the doctor when commencing use of
hormones. They are liable to experience complications or side-effects due
to the improper use of oils, injected by non-professionals in unfavourable
conditions. They lack economic resources for quality health care, facial
surgery, silicone buttock or breast implants, and gender reassignment surgery.
Aims of the programme
Tamaulipas Diversity VIHDA Trans A. C. promotes responsible sexuality, free
of sexually transmitted infections; human rights empowerment; and an end to
discrimination and violence against transgender people living with HIV/AIDS
and sex workers. This programme, active between January and December
2005, sought to achieve integral health care for transgender people who use
public health services.
50
Health promotion
A mobile centre provided care to HIV-positive transgender people. The
organisation trained and empowered transgender female sex workers on
human rights, condom negotiation and condom use.
Police authorities signed agreements that they would not arrest transgender
women while carrying out sex work. The programme also saw the legal
constitution of the first organisation of transgender women in the region, and
formed strategic alliances with other non-governmental organisations and
health authorities.
Challenges
There was little support from the head of the state HIV programme or from
the Tamaulipas Secretary of Health, since they have connections to organised
crime. Access to the transsexual labour group was very limited due to this lack
of support.
Best practices
Thanks to political advocacy a care programme was put together for
transgender people living with HIV.
51
Case Study
16
Peru
Partnership work between the
Association of Sex Workers Miluska,
Life and Dignity, Association for the
Rights of Trans People and Cayetano
Heredia University
Slow bureaucratic processes and medicine shortages cause difficulties in
accessing services and care.
A national sex work and human rights inquiry in 2007 brought together sex
workers of all genders, representatives of central and regional government
authorities, and civil society and international cooperation agencies,
to encourage broad debate on stigma, discrimination, violence and the
vulnerability associated with sex work and its links to HIV and AIDS. The
participation of sex worker organisations was a key element of the event.
Regional authorities committed to taking practical measures for an effective
programme of sexual and reproductive health and prevention of HIV in
sex work and human rights protection for this group in particular. The
programme was led by the Association of Sex Workers Miluska, Life and
Dignity, Association for the Rights of Trans People and Cayetano Heredia
University. It aimed to work with local and regional authorities with the
participation of the diverse kinds of organisations that had been represented
at the national inquiry, in a well coordinated manner designed to guarantee
human rights. Its goals were:
52
◗◗ to promote changes in the health sector and within the context of HIV
and AIDS, fostering the provision of sensitive support, with training and
information on sexual diversity and in relation to the complexity of the sex
work environment
◗◗ to reduce violence against sex workers, with special attention to law
enforcement officials and security forces at the local government level
◗◗ to improve sexual and reproductive health and HIV prevention services,
including condoms, universal access to STI treatment, information on STIs
and HIV and prevention methods
◗◗ to decrease stigma and discrimination by health care providers
◗◗ to advocate for changes in the municipal laws, particularly their attempts to
regulate sex work which result in the violation of sex workers’ human rights,
and
◗◗ to train government authorities, including the health sector, on the human
rights of sex workers, in order to decrease violence and stigma resulting from
their lack of awareness.
Its work was designed and carried out jointly with organisations of sex workers
and transgender people, along with academic institutions.
Challenges
Some fundamentalist authorities saw this as criminal work, and some
authorities with whom agreements had been made subsequently changed.
In some provinces the non-transgender female sex workers could not work with
the transgender sex workers because of different interests.
Ignorance about internet use made it difficult to make arrangements.
Best practices
The programme consolidated and
strengthened the capabilities of women
leaders, including transgender women.
Engagement with
law enforcement
A training module was developed
for police officers.
Engagement with health
service providers
Updating standards and protocols and
sensitising healthcare personnel led to
improvements in care and treatment
services for female sex workers,
including transgender women.
Forging alliances
Debate and advocacy took place to develop a legal proposal to recognise the
right to transgender identity, and advocacy took place for a legal proposal on
sex work.
53
54
Case Studies:
North America
and the Caribbean
In the Caribbean, reported rates of HIV among sex workers and
men who have sex with men are higher than among the population
as a whole (Caribbean Community and Pan‑Caribbean Partnership
Against HIV/AIDS, 2008; Baral et al., 2012; UNAIDS, 2010; UNAIDS,
2008; Global Commission on HIV and the Law — Secretariat, UNDP,
HIV/AIDS Practice, 2011). The USA and Canada see high rates of HIV
among sex workers who work on the street and sex workers who use
drugs (Jenness et al., 2011; Cohan et al., 2006; Shannon et al., 2005).
Region-wide issues are identified as meagre and declining funding
for HIV and sex work; repressive legal frameworks governing sex
work; stigma and discrimination towards sex workers, migrants
and LGBT people; anti-sex work ideology espoused by donors and
governments; inadequate HIV prevention, treatment, care and
support for sex workers; a lack of comprehensive
health programmes targeting sex workers in
the region; programmes and services
for sex workers which
have prejudiced
and unfounded
stereotypes of
sex workers and
moralistic views
opposing sex
work; and the
dwindling of
already meagre
funding for sex
worker-led HIV programming,
while anti-trafficking organisations
that intentionally conflate sex work
and trafficking are attaining an
increasingly large share of domestic
and global funding.
55
Case Study
17
Guyana
Guyana Sex Work Coalition (GSWC)
16.6% of female sex workers and 19.4% of male sex workers in Guyana are
HIV-positive. 78.6% of sex workers and 72% of MSM are not reached by HIV
prevention programmes.
Legal context
Sex work is highly stigmatised and criminalised. Laws prohibit solicitation,
procurement and ‘public indecency’ (Robinson, 2007). Laws that forbid ‘gross
indecency’ and cross-dressing have also been used to arrest and prosecute
MSM and transgender people, including those involved in sex work (Republic
of Guyana, 2012).
Police target sex workers for harassment and perform street sweeps, during
which street-based sex workers are arrested and detained under the guise
of enforcing laws against loitering and vagrancy. Sex workers are abused by
law enforcement officials and aggressors posing as clients, and discriminated
against by courts. When sex workers report crimes committed against them to
the police, their complaints
often go unheeded and in
some cases, they are ejected
from police stations because
of their work.
Access to
health services
Sex workers are mistreated
by health and social service
providers.
Access to housing
Sex workers are unfairly
evicted from their residences
by their landlords.
56
GSWC’s former Georgetown office and safe
space for sex workers.
Founded in 2008, the GSWC is the first national sex worker-led organisation
in Guyana. It fights for the human rights of sex workers in Guyana and the
Caribbean. The majority of staff and board members are sex workers, who
are involved at every level of decision making. It provides services in all ten
administrative regions of Guyana, working with sex workers of all genders,
including youth and HIV-positive sex workers, in both rural and urban areas.
Health promotion
The GSWC’s peer outreach teams visit sex workers at their workplaces, not
only distributing safe sex supplies but also engaging them in conversation
about their health, safety and human rights. Voluntary counselling and testing
for HIV and other STIs was available until July 2012 when funding cuts forced
the organisation’s Georgetown office to close.
The organisation’s workshops and
‘edu-dramas’ engage participants,
namely sex workers and members
of other marginalised communities,
in creative ways to learn about
issues like HIV and how to keep
themselves safe.
Human rights training, provided
to law enforcement officers, health
care providers, operators of sex work
establishments and others active in
the hospitality industry, makes use
of the ‘edu-drama’ model to educate
The GSWC visits Aranka (a rural
participants on issues prioritised by
community) to provide peer-based
sex workers, including stigma and
human rights education to sex workers,
and also distribute safe sex materials.
discrimination against sex workers,
LGBT communities and women and
girls; gender-based violence; access to
safe, effective and non-judgemental
police protection and health care; and confidentiality, particularly in health
care settings and in the context of police complaints. They present participants
with a fresh perspective and are effective in illustrating how sex workers are
driven away from services and how abusers operate in a culture of impunity.
Since the establishment of the GSWC and its engagement of the sex worker
community, sex workers have succeeded in raising public awareness of issues
including sex workers’ need for safe working conditions and the importance
of making condoms available in prisons. Sex worker advocacy eventually
led the Ministry of Health to adopt a ‘zero tolerance’ policy on stigma and
discrimination.
The GSWC has also passed on its knowledge to sex workers elsewhere in
the region, helping to establish the sex worker-led organisation Women of
Worth in Grenada, lobbying for better access to health and social justice in
Jamaica and Suriname, delivering training to regional sex workers on human
rights and advocacy, and participating in the NSWP and the Caribbean Sex
Worker Coalition.
57
Challenges
Loss of funding has led to the closure of the organisation’s Georgetown office,
which was the only safe space for sex workers in the country. This has had
a catastrophic effect on its ability to maintain essential programming. Some
services have since been provided out of the home of the GSWC’s executive
director but a more suitable space remains to be found.
Best practices
Workshops have led to ongoing peer support between sex workers, who
exchange safety tips and advice.
Because some people do not identify as sex workers but exchange sex for goods
or money, many of the workshops are not directed exclusively at sex workers,
but at marginalised communities more broadly. The GSWC contacts community
leaders in the area to invite participants. The focus is not specifically on HIV as
this may deter some from attending, but drama may be employed to illustrate,
for example, the relationship between gender-based violence and HIV.
Engagement with sex industry gatekeepers
The organisation held a workshop in 2009 for brothel and hotel owners
and participants from the hospitality industry to make them aware of,
and encourage them to uphold, sex workers’ human rights. This opened
meaningful lines of communication with hotel and brothel owners who in turn
help facilitate contact between the GSWC and sex workers residing in their
establishments.
Human rights training has led to a decrease in the high incidence of police
harassment of sex workers, greater willingness by police officers to take
the complaints of sex workers seriously, and fewer cases of discrimination
throughout the health sector. Police rarely obstruct the GSWC in the course
of outreach to sex workers working on the street. A particular success is the
GSWC’s training of police recruits through the Felix Austin Training College,
many of whom will begin their careers patrolling the streets.
Because of the training the GSWC had conducted with the police, sex workers
were able to coordinate public action to mark the International Day To End
Violence Against Sex Workers, 17 December, with the support and presence of
law enforcement. This was critical because of a history of passersby disrupting
sex workers’ public rallies, occasionally violently.
The GSWC visits the
New Amsterdam Law
Enforcement quarters
to conduct a human
rights workshop
with members of law
enforcement agencies.
58
Case Study
18
Jamaica
Sex Work Association
of Jamaica (SWAJ)
4.1% of sex workers in Jamaica, 32.8% of MSM and 12% of homeless people are
living with HIV (Jamaica, 2012). These figures contrast with an HIV prevalence
of 1.7% among Jamaica’s adult population overall. HIV rates are declining among
female sex workers, and most are reached by HIV prevention programmes, but
the legal situation continues to negatively impact sex workers, exposing them to
police harassment and deterring them from accessing services.
Legal context
Solicitation, ‘loitering’ in a public place for the purpose of prostitution, brothel
keeping, living off the earnings of prostitution and procurement are all
criminalised, as is same-sex intimacy.
Police harass and assault gay men and sex workers. Sex workers rarely report
violence to police, and if they do, arrests are rarely made.
Police crackdowns on sex work hamper outreach workers’ ability to distribute
condoms.
The prevalent tactics of policing drive sex workers underground and away from
potentially lifesaving information on HIV prevention and other health services.
59
The Sex Work Association of Jamaica was launched in 2008 by sex workers
after a meeting at which they had shared their experiences of stigma and
discrimination, including at the hands of health care professionals. Jamaica
AIDS Support for Life (JASL) had trained some sex workers as HIV and safe sex
peer educators, highlighting the need for sex worker leadership. SWAJ is a sex
worker-led and -run organisation advocating for sex workers’ rights and the
decriminalisation of sex work.
Health promotion
Peer outreach workers are trained on HIV education, harm reduction, safe
sex, working safely, advocacy, effective communication with clients and
others, condom negotiation and how to deal with clients who insist on having
unprotected sex. Services are implemented and delivered in partnership with
other organisations, such as JASL. To promote safe working conditions, JASL
encourages sex workers to work in a ‘buddy system’ so that they can support
one another. Mobile support is provided, accessing sex workers in remote areas.
Condoms and lubricants are distributed. The organisation also offers free and
confidential HIV testing, which can be anonymous if desired, and is carried out
by trained and certified sex workers, on a JASL bus or other vehicle. Referrals are
made to appropriate services.
The organisation documents human rights abuses and takes part in public
actions and campaigns to raise awareness of sex workers’ human rights and
to advocate for the repeal of laws that criminalise sex work. It engages with
print, television and radio media, and improves dialogue between sex workers
and police officers by training officers about the human rights of sex workers
and encouraging them to investigate sex workers’ complaints in an unbiased
manner.
Challenges
Numerous barriers exist to reaching indoor-based sex workers:
◗◗ club owners who claim to be unaware of sex work on their premises, due to
fear of being targeted or arrested for operating a brothel
◗◗ club owners who will not permit peer outreach workers onto their premises
◗◗ sex workers who do not see themselves as such and are resistant to outside
interventions
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Best practices
Because many sex workers in Jamaica are migrant and mobile, SWAJ stays in
touch with them by sending information via text message. This is made possible
through one of Jamaica’s major cell phone providers, which offered SWAJ a
platform to send bulk text messages. Sex workers who agree to provide their
phone numbers to SWAJ during outreach have their phone numbers uploaded to
an online database. When SWAJ wishes to send a message out concerning safe
sex, HIV and STI prevention, clinic operating days and hours, or appointments
for care, it loads this information onto the platform which is then circulated to
the telephone numbers in the database.
Rapid HIV testing has been very successful, because sex workers are able to
obtain their results within 20 minutes. Most sex workers are reluctant to visit
health centres where they have to wait all day just to get one test.
Police reported that the workshops were ‘eye openers’ and had greatly changed
their perceptions of sex workers. They also indicated that they were much more
open to working with sex workers to prevent violence committed against them
(Caribbean Vulnerable Communities Coalition & El Centro de Orientación e
Investigación Integral, 2013), and that they would like to participate in similar
training in the future, extended to more officers and covering more issues
related to sex work. Already, SWAJ members have noticed improvements in the
way police and sex workers relate to each other in the streets. Reflecting this
shift in attitude, Jamaica’s police commissioner issued a protocol in 2012 clearly
outlining how police officers should respectfully engage with marginalised
communities, including sex workers, when they file complaints with the police.
This was an extraordinary gesture in light of the history of police prejudice
against sex workers and due in large part to the input of SWAJ.
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Case Study
19
USA
Women With A Vision (WWAV)
Legal context
Sex work is highly criminalised in the state of Louisiana, where WWAV is based.
Engaging in ‘prostitution’ is prohibited and other aspects of sex work, such as
solicitation, promotion of ‘prostitution’, or ‘pandering’, are also criminalised.
Those accused of soliciting sex for money can be criminally charged under
the state prostitution statute, or under the solicitation provision of the ‘Crime
Against Nature’ statute which prohibits solicitation with the intent to engage
in anal or oral sex. Police and prosecutors have discretion in choosing which
charge to use against a sex worker.
Sex workers, especially those who are women of colour and transgender
women, are victims of police harassment, arrest, violence and other abuses.
Low-income communities in New Orleans have difficulties in accessing
affordable health care.
Access to housing
Rents continue to rise as gentrification takes root after Hurricane Katrina in
communities of colour. Access to affordable housing is affected.
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Origins and aims
of the programme
WWAV was established in the late
1980s in New Orleans by a grassroots
collective of eight Black women in
response to the spread of HIV in the
African American community. At the
time, there was only one organisation
working on HIV in the region and it
principally served White gay men.
WWAV’s mission is to improve the lives
of marginalised women, their families
and communities by addressing the
social conditions that hinder their
health and well-being. This includes extensive work with the lesbian, gay,
bisexual, transgender and queer (LGBTQ) community, and especially with
transgender women. For its first fifteen years, it focused on outreach and
prevention. Since Hurricane Katrina, the organisation has been increasingly
engaged in advocacy to address the social conditions and injustices that impact
New Orleans’ most marginalised women, including transgender women. Areas
of focus include sex workers’ rights and drug policy reform. While WWAV
traditionally serves Black women, the organisation has seen the demographics
of people in sex work change over time. More and more, WWAV reaches out to
low-income White women who have been hit hard by the US economic crisis.
Health promotion
WWAV conducts outreach to streets, hotels, bars and strip clubs, distributing
safe sex supplies, drug harm reduction, and education materials about HIV
and other STIs.
Access to justice
‘Know Your Rights’ sessions are held
with sex workers in partnership with
the Office of the Independent Police
Monitor of New Orleans to help inform
sex workers about their legal rights
when interacting with the police.
The organisation has a referral list of
lawyers who have experience working
with women and understand the
issue of criminalisation. A significant
achievement was WWAV’s partnership
with the Center for Constitutional Rights
to work on the ‘NO Justice’ campaign, which challenged Louisiana’s archaic
‘Crime Against Nature’ statute. Until 2011, sex workers convicted of ‘Crime
Against Nature by solicitation’ (SCAN) faced much harsher penalties, including
registration as a sex offender. They had to carry a state identification document
branding them as such in bright orange capital letters, and had to disclose
the fact that they were registered as a sex offender to neighbours, landlords,
employers, schools, parks, community centres, and churches. The campaign
succeeded in the removal of the requirement to register as a sex offender, and
over 800 individuals were removed from the registry.
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Community-centred meetings are held for different groups, such as people
who use drugs and people who have been incarcerated, and they take part
in advocacy campaigns. There is ongoing engagement with police, municipal
authorities and the Department of Justice to prevent the harmful arrest, police
harassment and incarceration of women and transgender people. WWAV is
currently in discussions with New Orleans public defenders, municipal court
judges, probation and parole officers and the district attorney to develop
alternatives to incarceration for women engaging in sex work or affected by
other punitive laws. In order to be heard by law enforcement and judicial
authorities, WWAV usually addresses sex workers’ rights from a public
health perspective by describing the disastrous impact on public health of
criminalising sex workers. Regular training is delivered to service providers,
including health care providers, to educate them about women’s challenges and
barriers to accessing health services, and to discuss stigma and sex workers’
rights. As a result, WWAV can refer women to non-judgemental and respectful
health services. The organisation responds to media articles and interventions
that reinforce prejudice against sex workers, women of colour and transgender
people.
Challenges
The criminalisation of sex work hampers WWAV’s work. Police attempt to
remove sex workers from tourist areas downtown and target African American
communities and transgender women for stops, searches and arrest.
Best practices
WWAV members bring condoms and harm reduction supplies with them when
they visit establishments such as beauty salons. This allows local women to pick
the materials up discreetly.
Demanding
justice
WWAV reached out
to those charged,
convicted, or at risk
of prosecution under
SCAN, as well as
allies and lawyers.
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Case Study
20
Canada
Maggie’s
Legal context
Criminal laws threaten sex workers in every sector, prohibiting public
communication for the purposes of prostitution, the use of indoor workspaces,
transportation to a working space, and managerial and/or collective activities.
In December 2013 the Supreme Court of Canada found these laws to be
unconstitutional, giving the Canadian parliament 12 months to rewrite them,
but until then they will continue to be enforced. At the time of writing, the
parliament appears to be leaning towards the Swedish model.
Maggie’s is one of North America’s oldest sex worker-led organisations, founded
in 1986 by a group of sex workers and their allies as a response to police
harassment of, and violence against, sex workers during the height of the
AIDS panic. Most of the staff, board and volunteers are current or former sex
workers. Its mission is to provide education, advocacy, and support to assist
sex workers to live and work with safety and dignity. It takes an intersectional
rights-based approach to sex work, recognising sex workers as individuals with
expert knowledge and as the best sources of relevant information for other sex
workers. It seeks to move beyond service provision to contribute to sex workers
organising to change the conditions under which they live and work.
Health promotion
The organisation provides education about HIV prevention, safe sex, and safer
drug use, and distributes drug harm reduction supplies.
The organisation runs various meeting groups for current and former sex
workers, including the Aboriginal Sex Worker Education and Outreach Project,
a three-year funded peer-based programme for and by Indigenous sex workers
which is the only programme of its kind in North America. The groups empower
sex workers to work safely, to engage in safe sex and safer drug use, and to
reduce violence in their lives.
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Access to justice
Maggie’s has a referral list of lawyers and offers court accompaniment.
Addressing violence
The organisation runs No List, a searchable online database of bad clients,
and provides short-term emotional support to sex workers who have
experienced violence.
Maggie’s educates other service providers and engages in advocacy for sex
workers’ rights and decriminalisation.
Best practices
Maggie’s reaches out to sex workers where they work, for example advertising
in the same places as them.
No List is compiled according to sex workers’ needs: physical descriptions
may be helpful but indoor-based sex workers need information such as email
addresses and phone numbers if they are to avoid meeting the individuals in
question.
Engagement with other service providers
A group-based labour analysis exercise is an effective learning tool when
educating other service providers. Groups identify links between sex work and
certain other (usually working-class) jobs, and consider how laws inform the
conditions for work.
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Best practices by sex workerled organisations
Offer services that meet sex workers’ needs
Drop-in centres
Establish drop-in centres to enable sex workers to access HIV prevention
services, including education, training, demonstration of condom use,
counselling, and HIV prevention tools including condoms, lubricants, reading
materials, and nutritional supplements for those on medication. Drop-in centres
should be in suitable and accessible locations and their opening hours should
suit sex workers’ schedules, bearing in mind that they may prefer to access
them at night.
Outreach
Conduct outreach activities to build rapport with the community and
disseminate information and education. Outreach should be informal
and sociable, playing an essential role in overcoming the isolation and
marginalisation faced by sex workers.
Reach out to sex workers where they work, for example advertising in the same
places as them. Some websites aimed at connecting sex workers with clients
may be willing to allow relevant support services to advertise for free or at a
discounted rate.
Where relevant, undertake partnership work with doctors and nurses to visit
sex workers in their homes in order to provide them with health examinations
and to impart health-related knowledge.
Telephone and internet support
Offer support online and by telephone. Services which can be flexible and adapt
to sex workers’ needs and preferences will have a higher uptake. The internet
is increasingly used by sex workers to connect with clients while keeping a low
public profile.
Investigate possibilities for sending bulk text messages in order to maintain
contact with as many sex workers as possible. Sending occasional messages will
not only deliver specific information to them, but will remind them that there is
someone there who can respond to their individual needs.
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Clinics
Where possible, refer sex workers to sex worker-friendly clinics for free and
welcoming services that enable them to access medication.
Ensure an anonymous, or coded, system is used for testing. A principal fear
among sex workers is that their occupation and/or test results will be exposed.
Reassurance that they needn’t give their names and that results are confidential
will encourage more sex workers to make use of available services. However, in
certain contexts employers may require sex workers to provide certificates with
their names on them, so ensure that this is possible if desired.
Offer rapid HIV testing, as sex workers may not have time to wait all day
for results.
Incentivise sex workers to visit clinics by employing such strategies as
reimbursement of transportation costs; provision of t-shirts or other free gifts;
and provision of relevant and desired services, such as hormone replacement
therapy which may encourage transgender women to visit.
Ensure that clinic staff carry out monitoring of service user adherence to
antiretroviral therapy.
Workshops
Hold workshops to increase sex workers’ knowledge about VCT, among other
issues, and to foster ongoing peer support between sex workers, who can
exchange safety tips and advice.
Focusing workshops specifically on HIV may deter some from attending. To
engage more participants, take a more holistic and creative approach, such as
employing drama to draw connections.
Addressing violence
Circulate information among sex workers on violent and time-wasting
clients. Compile lists according to sex workers’ needs, bearing in mind that
physical descriptions are not necessarily enough: to protect themselves from
dangerous individuals, indoor-based sex workers may require details such as
email addresses and phone numbers. Be aware of laws regarding the personal
information that can be given out about individuals whose crimes are alleged
rather than convicted. Connect with other sex worker organisations around the
world to learn of the strategies they have taken to balance legal constraints and
sex workers’ safety.
Crisis intervention
Ensure strong and quick crisis intervention. Demonstrate that the organisation
is worthy of sex workers’ trust and that it is looking out for them. Crisis teams
should be well trained to deal with police, sex industry gatekeepers and
other parties.
Follow-ups
Conduct continuous routine follow-ups, through peer educators, for HIV-positive
sex workers, to ensure that their needs are met, to gather feedback for better
quality HIV/AIDS-related services and to determine what has been achieved in
advocacy efforts.
Monitor risky behaviour among sex workers and attempt to reduce it with the
help of counsellors and outreach workers.
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Ensure that funding sources have sex workers’
best interests at heart
In today’s unstable funding environment options are often limited, but sex
worker-led organisations should nonetheless do everything in their power
to prioritise the needs of their local sex worker community, rather than
succumbing to the orders of international NGOs.
An alternative to receiving funding from an external agency is the union model,
whereby organisations receive monthly fees from members and are therefore
accountable to the community and answerable to the fee-payers.
Resources may be sourced from within the community, especially if that
community encompasses people of many trades, as in the case of PT
Foundation’s transgender programme in Malaysia. The help of community
members in organising events and campaigns can reduce financial cost.
Run services effectively and smoothly
Map sex workers in the district in order to help outreach workers reach out to
the community.
Regularly update information during (de)briefings.
Keep secure records on service users to enable the updating of information and
ensure appropriate services are delivered.
Ensure inclusion of all sex workers
Recognise that some people do not identify as sex workers but nonetheless
exchange sex for goods or money. To reach them, some of the activities on
offer should not be directed exclusively at sex workers, but at marginalised
communities more broadly. Bring condoms and harm reduction supplies to
venues which are not used for sex work but may be frequented by sex workers,
such as community centres or beauty salons, allowing locals to discreetly pick
up materials and find out about the services on offer.
Involve both HIV-positive and -negative sex workers in the governance and
leadership of the organisation.
Ensure there are sufficient activities to meet the needs of migrant sex workers.
Aim for programming led by sex workers
Train sex workers as paralegals to collect information from their colleagues on
human rights abuses and violence.
Train sex workers as HTC counsellors.
Train sex workers as peer educators to ensure the provision of services in a
friendly environment, reaching their colleagues with HIV prevention messages
and safe sex supplies and encouraging them to learn their status at HTC centres
and seek treatment if HIV-positive.
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Aim for community empowerment
Empower and mobilise sex workers to understand and know their rights, to
demand quality services and access to care, to understand policy analysis skills,
to form strong advocacy groups from the community level, and to improve
communication skills.
Create support among sex worker communities for government health policies
that affect them positively, as well as the removal of discriminatory laws.
Consolidate and strengthen the capabilities of sex worker leaders.
Hold capacity-building workshops and training to assist with the provision
of practical information, to raise awareness of the health and welfare needs
of HIV-positive sex workers, and to enable empowered and skilled HIV peer
educators to demand quality services.
Make use of social media to reach out to members of the community and to
organise community events.
Consider establishing a separate online advocacy and/or community group.
Additionally, shifting focus away from the programme itself may be beneficial in
terms of security in countries where sex workers, LGBT people or other relevant
groups are targeted by repressive laws and widespread prejudice.
Engage with sex industry gatekeepers
Hold workshops and train brothel managers and venue owners on HIV
prevention approaches and sex workers’ rights, encouraging them to make an
effective contribution towards the reduction of new infections, the reduction of
client violence against sex workers, and knowledge sharing on HIV prevention
with sex workers. This may open meaningful lines of communication with
them, facilitating contact between the programme and sex workers working in
their venues.
Engage with the government
Engage in consistent networking and consultations with government agencies,
taking a human rights-based approach. Hold discussions with policy makers
to change oppressive laws and policies. They may not be committed to the
same goals, but it is important that representatives of sex workers, transgender
people, people living with HIV and other marginalised groups have a seat at the
table. Even small achievements can make improvements to their lives.
Engage with law enforcement agencies
Take a human rights-based approach in lobbying and advocacy activities with
law enforcement personnel. This may be successful in encouraging police
officers to protect the rights of sex workers, and even to help them with the
distribution of condoms, as has resulted from BHESP’s work in Kenya.
Develop a working relationship with law enforcement agencies where possible.
Encourage police to hold discussions with sex workers on how the police could
effectively help protect their rights.
Develop a training module for police officers and challenge their perceptions of
sex workers. Human rights training can lead to a decrease in police harassment
of sex workers, greater willingness by police officers to take the complaints of
sex workers seriously and a commitment to work with sex workers to prevent
violence committed against them. Raising police awareness may also dissuade
them from obstructing outreach to street-based sex workers, and gain support
from law enforcement when sex workers hold public actions and rallies.
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Engage with health professionals
Update standards and protocols and sensitise healthcare personnel to encourage
improvements in care and treatment services for sex workers. Provide human
rights training to reduce cases of discrimination by health sector professionals.
Deliver training to health professionals and other service providers to educate
them on issues faced by sex workers and other marginalised groups and to
reduce discrimination and inadequate service provision. Incorporate a groupbased labour analysis exercise enabling participants to identify links between
sex work and certain other (usually working-class) jobs, and consider how laws
inform the conditions for work.
Engage with the media
Target the media to change the perceptions of sex work which filter through to
the general public. Build a network of reliable journalists and other allies, as has
been done by Rose Alliance in Sweden, which has also established an award for
those working for positive change.
Demand justice
Develop legal proposals on sex work and other relevant issues, such as
recognition of the right to transgender identity.
If the organisation is in a position to challenge unjust laws, reach out to those
charged, convicted, or at risk of prosecution under them, as well as allies
and lawyers.
Forge alliances
Liaise with human rights organisations to assist sex workers in finding pro bono
legal representation.
Network with civil society organisations to enable sex workers to receive
training on HIV prevention, treatment, care and support and sex workers’ rights.
Network and collaborate with different groups in order to mainstream the
issues of sex workers, LGBT people and other relevant groups, reaching a wider
cross-section of the public.
To build a national network from the ground up, involve sex workers, health
professionals, international development, feminists, and other key affected
populations.
Partner with other local, regional and global sex worker-led organisations
and networks to ensure sex workers can access better treatment, care and
support, as well as to engage in policy review activities with the aim of violence
reduction and improved prevention efforts.
Liaise with rights groups and national networks of sex workers to speak out
about their situation in various forums.
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Recommendations
Between them, the consultants and the programmes studied came up with a
great deal of recommendations, aimed variously at sex worker-led organisations,
other service providers, donors, governments and policy makers. The breadth of
these recommendations illustrates the range of factors which continue to leave
sex workers vulnerable to HIV and human rights violations.
A combination of approaches is required. HIV and other health services need
to be improved to meet sex workers’ needs, but well informed and respectful
staff, and the availability of condoms, can only go so far if laws and policing
continue to put sex workers at risk. Sex worker-led organisations should be at
the forefront of protecting sex workers from HIV and should always be mindful
of the diversity of the sex work community, rather than focusing on a narrow
selection of sex worker identities. In every intervention, it should be recognised
that sex workers may suffer from other forms of discrimination in addition to
stigma against sex work. An understanding of how different forms of oppression
and injustice intersect is required.
Consideration should be given to how each recommendation can be put
into practice with the inclusion of a wide range of sex workers, among them
transgender sex workers, male sex workers, sex workers from ethnic minority
groups, indoor-based sex workers, rural sex workers, sex workers who use
drugs, HIV-positive sex workers, incarcerated sex workers, illiterate sex workers,
sex workers with disabilities, documented and undocumented migrant sex
workers, and sex workers who require support in other languages.
Prioritise sex worker-led interventions
An overarching theme is that sex workers must be recognised as the experts
on their own lives, needs and circumstances, if interventions are to succeed.
As identified in the Europe report, the
‘prevention gap’ calls for an immediate, well informed, and holistic
intervention. That kind of intervention – to be effective and successful –
requires sex workers’ direct involvement, participation, and leadership
in the development, implementation, and evaluation of comprehensive
HIV programming dedicated to the sex worker community. Sex workerled organisations play a significant role because they can recognise sex
workers’ actual needs and expectations with regard to HIV prevention
and treatment, determine priorities for action to ensure sex workers’
unconditional access to HIV-related services, and undertake collective
action to overcome socio-environmental barriers contributing to sex
workers’ vulnerability to HIV.
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Maggie’s in Toronto outlines why sex worker-led interventions are necessary:
Because staff have sex work experience, they can provide information that
is specific to work in the sex industry. [...] Mainstream information is often
too generic to be useful to sex workers because there is no understanding
of the context within which sex work takes place. As one staff member
explained, ‘Telling sex workers to use condoms isn’t helpful because sex
workers already know this.’ What sex workers often need is information
that is relevant to the sex industry. One staff member reinforced this
point, ‘If you’ve never sucked a dick for money, you don’t have cultural
competency in providing services to sex workers. You can support it, but
you shouldn’t be the direct service provider.’
Too often, service providers with no experience of sex work base their decisions
on poor information and stereotypes about the sex industry. Around the world
sex workers have proven that they are capable of delivering services to, and
advocating for, their own communities. Their knowledge must be prioritised in
service delivery or the ‘prevention gap’ will endure.
Base services on evidence, responding to actual needs
Specific and up-to-date data on sex work is required, with more groups
profiled and more research carried out. It is imperative that this research is
conducted ethically, with the use of methodologies that include the sex workers
themselves. It should avoid focusing solely on cities, as more insight is needed
into sex work in places that are less accessible. Local authorities should invest in
consistent resources to generate strategic information through studies.
In particular, governments and funders should ensure that funded antitrafficking initiatives are evidence-based, grounded in human rights and
have involved meaningful consultation with sex workers. Given the human
rights violations experienced by sex workers in the name of anti-trafficking
interventions, this disconnect is another key component of the ‘prevention gap’.
Prioritise sex workers’ needs over those of funders
As stated by the Guyana Sex Work Coalition, “For too long, funders have sat in
their ‘ivory towers’ dictating down to sex workers. […] We know exactly what it
is like to be a sex worker, what we need and what we are facing.”
It is frequently the case that services aimed at sex workers focus solely on HIV
and STI prevention through the promotion of safe sex and safer drug use. While
these are certainly worthwhile endeavours, they fall short in their failure to
look at the bigger picture of what sex workers want and need, often due to a
lack of funding for more extensive programming. It must be recognised that
not only do sex workers deserve holistic support such as access to information
on dangerous clients, legal advice and support in their dealings with the police,
but these issues are all connected with their holistic health needs. The more
empowered that sex workers are, the more they can protect themselves from
HIV and STIs. Funders may not be able to change the laws that disadvantage
sex workers, but they are in a position to ensure the provision of more suitable
services which strengthen the sex worker community and thereby reduce risks.
Governments and funders should adopt a rights-based approach to funding
by supporting sex worker-led HIV programming that encourages sex
workers’ leadership and meaningful participation in the development and
implementation of health services relevant to and for sex workers. They should
recognise the value of community-led programming and interventions in
reducing sex workers’ vulnerability to HIV infection and providing them with
comprehensive HIV programming. Thus they should support – financially,
educationally, and technically – the development and strengthening of the sex
worker community and sex worker-led organisations.
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However, because relatively few donors presently support projects that directly
represent sex workers’ interests, sex worker-led organisations must be aware
of and able to respond to the changing funding environment and diversify
sources of funding in order to guarantee sustainability and continuity of HIV
programming. They should be prepared to negotiate the terms and conditions of
funding and define the limits of what they are willing to accept. If donors set the
terms without engaging in real research or dialogue, sex worker organisations
may end up spending a large proportion of necessary funds on achieving goals
they do not agree with or fulfilling needs which they know not to be the most
pressing ones.
Enhance sex worker-led organisations’ access to funding
Donors should work towards simplification of funding application procedures,
thus widening the access of sex worker-led organisations to grant opportunities
and improving the feasibility of their projects. Funding opportunities for
comprehensive HIV programming should be available to all eligible sex workerled organisations in low-, middle-, and high-income countries, especially given
that sex workers remain a marginalised group experiencing discrimination and
stigma globally. Adequate long-term funding needs to be provided to sex workerled organisations so that they can establish a safe space for sex workers in an
accessible and suitable location which is open at convenient times, in which
HIV-related programming and shelter can be offered among other services.
Promote decriminalisation and law reform
The call for decriminalisation comes from sex workers in every corner of the
world. It is strongly recommended that all countries engage in discussions to
decriminalise sex work and eradicate the unfair use of unsupported laws and
regulations to violate sex workers’ rights. Implementing this recommendation
is critical because it will reduce harassment of sex workers by police as well
as reducing the stigma and discrimination that sex workers face, enabling
them to seek and access health care services without fear. Additionally, all
discriminatory and repressive laws and regulations which contribute to sex
workers’ vulnerability to HIV infection should be eliminated. These include
laws criminalising HIV exposure, non-disclosure, and transmission; same-sex
activity; transgender identity and associated behaviours; and drug use; as well
as civil and administrative offences that punish sex workers under the guise of
enforcing laws against vagrancy, public nuisance, loitering or similar policies.
Furthermore, it is crucial to repeal or amend laws against human trafficking
that conflate human trafficking with sex work or that are enforced to prohibit
sex work. Absorbing a campaign against consensual sex work into the fight
against human trafficking obscures the main goal, diverting resources away
from tackling the actual abuses suffered by victims of trafficking, while placing
sex workers in jeopardy. If human trafficking is to be tackled effectively,
work carried out must focus clearly on what will actually benefit those who
experience it, rather than ideology and unsupported claims.
Involve sex workers in law and policy
reform and development
Governments should meaningfully involve sex workers in law and policy
reform, in order to take into account their views about how to minimise the
potential for harm. Actively engaging sex workers would send a powerful
message that law-makers are willing to listen rather than talk over them.
Mechanisms can be put in place to protect anonymity where desired. It is
essential that governments engage with sex workers respectfully, recognising
that sex workers are diverse and that all deserve to be heard regardless of
whether they fit the audience’s preconceptions.
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Afford protection under the law
Governments should undertake legal actions and introduce policy mechanisms
that explicitly protect sex workers from discrimination, violence, and other
human rights violations committed by law enforcement agencies, clients,
service providers, the general public, and the media, which contribute to
sex workers’ vulnerability to HIV infection. These actions should be taken
through working together with sex workers themselves and sex worker-led
organisations.
Legislation should be adopted protecting sex workers and other marginalised
communities from discrimination based on occupation (including sex work),
health status (including actual or perceived HIV status), sexual orientation and
gender identity. This legislation should be well publicised and its enforcement
ensured, making both sex workers and those who would abuse them aware that
such behaviour will not be tolerated.
Enforce zero tolerance of police abuses
Measures must be taken to stop police harassment and violence against sex
workers. Around the world it is a common occurrence for police to unfairly
target and abuse sex workers with impunity, and radical changes may be
required before sex workers will perceive the police as protectors instead
of persecutors. Complaints should be followed up promptly and adequate
support provided. Law enforcement authorities should engage with sex worker
communities and demonstrate accountability. Specially trained police liaison
officers who do not have an enforcement role may be beneficial in dealing with
sex workers’ concerns and acting as an intermediary between sex workers and
the wider police force.
Grant access to labour rights
Governments should recognise sex work as work and grant sex workers labour
rights, thus entitling them to state benefits and access to social, financial, and
medical services, including high-quality HIV prevention, testing, treatment,
care, and support. Safe working conditions should be ensured, including by
protecting sex workers’ rights under employment standards and occupational
health and safety legislation.
Enhance awareness about rights
Efforts should be made to raise sex workers’ awareness about their rights with
regard to various issues. This applies not only to the legality of sex work, but
to applicable legislation on sex work and HIV, including laws on HIV exposure,
disclosure, and transmission. They should also be made aware of their rights in
terms of interactions with the police and with health and social services, and
empowered to make complaints and seek redress should their rights be violated.
Document human rights violations
Governments and funders should support human rights documentation and
training developed and led by sex workers to combat stigma, discrimination
and judgemental approaches from service providers (including law enforcement
officers and health care workers) towards sex workers and other marginalised
groups such as MSM, transgender people and people who use drugs.
Eliminate coercive testing
Coercive testing for HIV and/or other STIs is of grave concern to the sex worker
community worldwide as it does not respect sex workers’ rights, dignity,
privacy, or confidentiality. It should be prohibited and legislation authorising it
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should be repealed. In its place should be a recognition that sex workers have
the right to decide for themselves when, where and whether to get tested,
and that they can be encouraged to do so with the provision of respectful and
confidential testing services, along with accessible and affordable treatment
should they test positive.
Address structural inequalities
Governments should address the structural issues that contribute to HIV
vulnerability in the context of sex work, and provide meaningful interventions
that aim to reduce poverty and inequality, create and expand employment
opportunities, and ensure education for all. This should not be done with the
intention of eradicating sex work and thereby reducing sex workers’ options;
instead, the aim should be to expand the range of options open to people, while
respecting their right to engage in sex work if it is their preference.
Ensure inclusion of transgender sex workers
HIV programmes should integrate sex workers of all genders from the
beginning. Transgender women should be separated from the MSM cluster, as
the conflation of the two groups perpetuates transphobic attitudes and does
not adequately reflect their needs or identities. Transgender female sex workers
must be recognised as women. Services aimed at female sex workers should
be well informed on transgender issues and service providers should be able
and willing to meet transgender female sex workers’ needs in a welcoming
and respectful space. In addition, research is needed on transgender male sex
workers and those who identify outside of the gender binary. These groups
are rarely acknowledged, and care must be taken to ensure that they are not
marginalised or alienated from services.
Empower the sex worker community
Community empowerment is an effective tool in reducing the exposure of sex
workers to HIV. It gives sex workers more control over their working conditions
as well as control over preventing new infections. It also helps in addressing the
obstacles impeding sex workers’ access to health services, and protects against
human rights violations. To foster community empowerment, continuous
engagement is needed with sex workers to participate in raising awareness
of sex workers’ rights and establishing community-led drop-in centres. The
focus should also be on creating solidarity and shared efficacy to improve
engagements in outreach and advocacy.
Form trade unions
The union model, such as that taken by the Karnataka Sex Workers Union
in India, can be effective particularly in countries where community-based
organisations are weak and unable to take on governments and donor
organisations. It enables sex workers to come together and collectively demand
labour and other rights, without relying on funding from outside sources.
Avoid hierarchies
Members of sex worker collectives should have an equal share of power,
applying democratic principles in decision-making processes and building
organisational capacity.
Harness the internet in service provision
The internet is increasingly used by sex workers as a means to make contact
with clients and with each other while keeping a low profile from the police
and the general public. This is particularly evident in Sweden, but it should be
76
noted that internet use as a means to connect with clients is not restricted to
sex workers in the Global North. Many sex workers appreciate the opportunity
to access support online from sex worker-led organisations which understand
their issues and respect their confidentiality.
Make use of social media in advocacy work
Capacity-building training is recommended to include maximising advocacy via
social media, often a cheap and effective tool in educating the public on issues
faced by sex workers and in forging links with local and international allies.
Information disseminated through discussion boards, social media and other
websites informs the public on the realities of sex workers’ lives and helps to
reduce the stigma and prejudice that they experience.
Given crackdowns on social media in certain parts of the world, as well as the
sometimes arbitrary suspensions of groups’ and individuals’ Facebook and
other social media accounts, activists should be aware of the pros and cons
of different platforms and ensure they can still access the contacts they have
established should their accounts be compromised. Online security measures
should be taken to ensure protection and additional resources made available to
manage online advocacy.
Strengthen local, national, regional and
global sex worker networks
Sex worker-led organisations are encouraged to connect with other sex worker
collectives, organisations, and networks on the local, national, regional, and
global level. Mutual support, communication, and the exchange of knowledge
and experience can help to improve HIV programming projects offered by sex
worker-led organisations.
Regional advocacy networks should incorporate human rights into the
framework of internal mechanisms, with advocacy materials made readily
available to decision-making components of the sex worker groups. The
community will be strengthened by a united voice highlighting not only
localised issues but drawing connections between the experiences of sex
workers in the wider region and beyond.
Build coalitions and alliances across sectors
Coalitions and alliances should be built with health care professionals, lawyers,
human rights activists, policy makers, local and national governments, nongovernmental organisations, representatives of the private sector or media, and
other stakeholders who support sex workers’ rights. A training system should be
set up to promote alliances between organisations, authorities and sex workers
so that sex workers do not only receive condoms but also become promoters
and agents of change in their own right. In addition, alliances are particularly
recommended between HIV/AIDS groups and government.
Involve sex workers in service development
Sex workers should have meaningful participation in decision making as well
as in the development, implementation, monitoring, and evaluation of related
projects and resources dedicated to members of their community. Governments
and funders should ensure that sex workers are essential partners and leaders
in designing, planning, implementing and evaluating health, social and legal
services for sex workers. Strategies and actions on HIV and sex work should
be incorporated into national HIV/AIDS plans or strategies, with meaningful
consultations with sex workers. These should be inclusive of illiterate and
migrant sex workers, and as such translated materials may be required as well
as non-written means of conveying information.
77
Ensure access to social and legal services
Governments and funders should support and ensure accessible, nondiscriminatory, user-friendly and affordable social and legal services to promote
sex workers’ access to stable housing, education and employment opportunities
of their choice.
End discrimination in access to health services
Sex workers – regardless of their gender, sexual orientation, work environment,
socio-economic status, and ethnic origin – should be granted unconditional
access to the highest attainable standards of HIV prevention, as well as primary
and secondary health care. Services should be accessible to people who use
drugs without fear of disclosure of their drug use to authorities. Health service
providers should maintain a congruent relationship with services assisting sex
worker groups which understand the reality of what is actually happening in
terms of sex workers’ health issues. Sex workers should be accompanied and
empowered to make complaints, and to know which authorities to go to and
how to follow up. They should be trained to empower themselves and bring to
justice all cases of rights violations within the health services. Governments
and funders should reject coercive programmes that pressure and/or require sex
workers to leave sex work, reduce involvement in sex work, oppose sex work or
identify oneself as a trafficked person in order to access services.
Ensure access to HIV services for all migrants
In particular, governments should grant access to health care, including HIV
treatment, to migrants and undocumented persons without fear of disclosure
of their HIV or immigration status to the authorities. All legal barriers and
discriminatory provisions preventing documented and/or undocumented
migrants from accessing high-quality HIV prevention, counselling, testing,
treatment, care, and support should be removed. These barriers include the
deportation of HIV-positive migrants.
Ensure that health services are appropriate and accessible
Governments should ensure that health services, including primary health care,
sexual and reproductive health care, and HIV-related services, are appropriate,
accessible, and acceptable to sex workers, avoiding stigma and discrimination
while enhancing the promotion of their right to health. This recommendation
will drastically minimise the stigma associated with HIV and sex work in health
care settings. To achieve this goal, health care providers should be sensitised to
the rights and needs of sex workers, including non-coercive services, freedom of
choice, confidentiality, and informed consent. Training on these issues should
be carried out in partnership with sex workers. The government needs to work
with sex worker-led organisations in designing, implementing, and evaluating
health care services offered to sex workers.
Ensure that services are inclusive of all sex workers
Service providers need to recognise the diversity within the sex worker
community and try to address the real needs of those sex workers who are the
most vulnerable and marginalised, and thus to the greatest extent affected
by HIV. It should be remembered that, rather than constituting an obstacle,
the diversity of sex workers’ realities, lives, and experiences is an enormous
asset in problem-solving and the main source of creativity in developing
effective HIV programming. All HIV programming projects should take into
account this diversity, including consideration of indoor, male, transgender,
and migrant sex workers, sex workers who use drugs, and those living
with HIV. The cultural and language diversity of the sex worker community
should be adequately addressed. Governments and funders should support
78
sex worker-led HIV programming that provides peer support for a diversity
of sex work communities, including Indigenous sex workers, sex workers of
colour, LGBT sex workers, sex workers who use drugs, youth sex workers,
incarcerated sex workers, migrant sex workers, and sex workers in rural and
remote communities.
Promote and provide safe sex and drug
harm reduction supplies
Condoms and lubricants should be made easily available to sex workers, and
their correct and consistent use should be promoted. Community-led approaches
to the promotion, distribution, and education of safe sex supplies should be
supported. Prophylaxis programmes should take into account the particular
needs of sex workers. Governments and funders should supply sex worker-led
organisations with safe sex materials and safer drug use equipment, including
sterile injection and smoking equipment.
Promote and enable access to asymptomatic STI screening
Sex workers should be educated about the significance of seeking screening
services for asymptomatic STIs, and discouraged from waiting until symptoms
of STIs materialise, instead seeking laboratory screening when exposed to risks.
It remains imperative that such screening is voluntarily sought and accessed.
Promote voluntary HIV testing
Voluntary HTC services should be promoted to sex workers as provided for
under the current World Health Organization HTC guidelines. Comprehensive
programmes should be put together which provide free and confidential HIV
testing, not only in hospitals, but reaching all areas where there is sex work.
Testing should be linked to HIV treatment, care and support services, and all
HIV-related services for sex workers should be provided with informed consent
and in accordance with human rights standards.
Address sex workers’ vulnerability
to HIV in all its complexity
Issues related to internalised stigma, discrimination, violence, and other forms
of sex workers’ rights violations should be addressed within the framework
of HIV programming given that they contribute to sex workers’ vulnerability
to HIV and deter them from accessing HIV-related services. As crucial tools in
challenging the HIV epidemic, donors should recognise and support communityled projects aimed at documenting and combating human rights violations,
discrimination, and violence against sex workers, as well as other advocacy
campaigns addressing discriminatory and repressive legal frameworks.
Address sex workers’ needs beyond HIV
The work of sex worker-led organisations or collectives should not only provide
sex workers with comprehensive HIV prevention; it should also address
discriminatory and repressive legal frameworks affecting the effectiveness and
accessibility of HIV programming. HIV programming should actively challenge
human rights violations, discrimination, stigma, and all forms of violence faced
by sex workers, including physical, psychic, sexual, economic, and structural
violence (resulting from widespread social stigma, homophobia, transphobia,
xenophobia, religious fundamentalism, and so on), contributing to sex workers’
vulnerability to HIV infection. The mobilisation, self-organisation, and selfdetermination of the sex worker community should be actively supported
through the provision to sex workers’ collectives of meeting spaces, training, and
other resources facilitating their involvement in response to the HIV epidemic.
79
Conclusion
Considerable changes are required globally if sex workers are to fully enjoy the
right to health and protection from HIV and other STIs. In many cases, a radical
overhaul of the system is needed in order to stamp out the discrimination that
prevents sex workers from accessing appropriate services and support.
Governments, service providers and funders must make the switch from
policies based on ideology to pragmatic responses based on evidence, respect
for sex workers’ human rights, and acknowledgement of the complexities
and intersectional oppressions affecting sex workers’ lives. Police abuse of
sex workers is a particularly troubling phenomenon and must be tackled
from multiple angles, including sensitisation of police officers; clear and well
publicised commitments to ending police violence; channels through which
sex workers can report abuses suffered at the hands of police, with confidence
that justice will be served; and a repeal of the laws which encourage police to
persecute rather than protect sex workers.
All changes to the laws on sex work must be carried out in consultation with sex
workers themselves; for too long, others have spoken over them. Furthermore,
it is not sufficient to only include former sex workers: those presently engaged
in sex work are the ones who remain affected by policies and legislation. Law
changes which are based on ideology rather than evidence run the risk of using
current sex workers as guinea pigs: an unacceptable strategy. Sex workers’ lives
are not to be experimented with.
Given the persistence of stigma, efforts to include sex workers should extend
to the granting of anonymity and alternative methods of engaging in public
discussions. The media have considerable influence on public attitudes, and sex
worker-led organisations should engage with journalists to educate them on the
importance of centring the voices of sex workers themselves on the issues that
affect them.
The organisations profiled in this report have come up with creative ways to
tackle HIV among sex workers, and in doing so have empowered sex workers
to find community among their colleagues, to protect themselves, to gain
confidence and to demand rights. They have succeeded in reaching out to
marginalised groups who are often, due to previous negative contact with
services, distrustful of outsiders. Restriction of their work, whether in the form
of funding constraints, denial of registration, obstructive policing, or continued
discrimination by health and social services providers and policy makers,
is counterproductive to HIV prevention efforts, benefiting no one. Rather
than enacting further clampdowns on sex workers and other marginalised
communities, perpetuating stigma and abuse in the process, it is time for the
efforts of these organisations, which centre sex workers’ agency and human
rights, to be celebrated and expanded, leading to genuine improvements
in health.
80
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Sex Worker-Led HIV Programming Global report

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